Managing pain when preparing patients for air transport FOCUS IN THIS ISSUE
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Canada's Health Care Newspaper SEPT. 2015 | VOLUME 28 ISSUE 9 | www.hospitalnews.com
Innovations in emergency and trauma delivery systems. Emergency preparedness issues facing hospitals and how they are addressing them. Advances in critical care medicine. Programs implemented to reduce hospital acquired infections. Developments in the prevention and treatment of drug-resistant bacteria and control of infectious diseases.
Making the most of newer diagnostic technologies
INSIDE Data Pulse ..........................................11 Ethics .................................................. 14 Legal Update ......................................19 Evidence Matters ............................... 27 Nursing Pulse .....................................28 From the CEO's desk.......................... 31 Careers ...............................................39
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Antibiotics – overprescribed and under-effective
Why antibiotic resistance can be deadly By Brian W. Rotenberg
am privileged to help patients deal with a variety of common disorders such as ear infections, pharyngitis and sinus inflammation. People suffer a great deal from these problems, especially when they are in the acute phase. I offer pain medication, ear or nasal rinses, gargles or decongestants, all of which work reasonably well. The overwhelming majority of these incredibly common infections are caused by viruses – that is, they will not respond to antibiotics – so I don’t routinely offer antibiotic treatments. When patients hear they won’t be getting an antibiotic many become surprised and often upset. I then spend time counseling them about why antibiotics are, in most cases, the wrong treatment choice. Let us use sinusitis as an example to frame the discussion. In 2013, according to Health Canada, almost five per cent of the Canadian population was diagnosed with an acute sinus infection. This represents almost two million Canadians. Of these people, the same study reported that approximately 85 per cent received an antibiotic prescription. However, the disturbing part is that according to the modern Canadian Sinusitis Guidelines published in 2011, 98-99.5 per cent of people with sinusitis actually have a viral infection without bacteria. Therefore, the vast majority of people receiving the antibiotic not only didn’t need the therapy, but were actually treated incorrectly. Antibiotics are a precious resource that, if used appropriately, can be lifesaving and curative. However, the overuse (or “misuse” as some might say) of antibiotics in humans has led to the de-
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velopment of many types of antibioticresistant bacteria that fail to respond to these agents – and that can be deadly. Antibiotic resistance is now a major global public health problem with serious societal costs. Since antibiotic resistance genes are shared between bacteria in our ecosystem, inappropriate use of antibiotics – even in a single individual – could potentially affect every living creature on earth. In Canada we live in a blessed country where most acute infectious illnesses of the past have become rare enough to have faded from memory. Most of our current health care dollars now go towards treating chronic conditions, many of which involve surgical treatments, such as hip and knee replacement to treat arthritis. These surgeries simply could not happen if they carried a major infectious risk. Having an implant get infected is devastating to a patient. Imagine if your grandmother couldn’t have her hip replacement surgery because the risk of developing an antibiotic resistant infection was too high. I don’t believe I’m exaggerating when I say this risk is a real possibility in our lifetime. Modern society eschews disease, and nobody feels they have time anymore to be sick. A reasonable level of tolerance for mild viral illness has largely been replaced by self-maximization of symptoms and requests for aggressive therapy, most commonly antibiotics. It is a rare patient who is satisfied with time honored and effective conservative measures – drink plenty of fluids, take some pain medication and wait a few days for it to get better.
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More problematically, it is also becoming a rare doctor who will take the time to educate patients that in all likelihood their infection is viral, and won’t respond to antibiotics anyway. Sometimes it is easier to just write a prescription. Add to this the fact that pharmaceutical makers have been lackluster in developing newer antibiotics as the costs associated with drug development make such ventures very risky. You are more likely to see instead lifestyle medications such as cholesterol pills or blood pressure medications, which are far more lucrative for pharmaceutical firms. And here’s a strange fact of history: did you know that most of the current types of antibiotics were discovered by scientific accident, and that the targeted research fostered by modern society has been notably unsuccessful in replicating the happy serendipity of our historical scientists? When was the last time you heard of a new type of antibiotic being released for use by physicians? It would be wonderful to see a willing wealthy philanthropist, or a strong government leader, partner with big pharma to set a financial motivator for antibiotic development. Absent that though, society in general needs a reset for how antibiotics are regarded and used, and physicians in particular need to stop overprescribing them. It really is ok to just be sick for a little H while with a virus. ■ Dr. Brian Rotenberg is an expert advisor with EvidenceNetwork.ca and an Associate Professor in the Department of Otolaryngology – Head & Neck Surgery at Western University, London, Ontario.
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Birth factors may predict schizophrenia in genetic subtype of schizophrenia Low birth weight and preterm birth appear to increase the risk of schizophrenia among individuals with a genetic condition called the 22q11.2 deletion syndrome, a new study from the Centre for Addiction and Mental Health (CAMH) shows. The research, published in Genetics in Medicine, is “…part of ongoing efforts among schizophrenia researchers to predict and prevent illness at the earliest stages possible,” says senior author Dr. Anne Bassett, Clinician-Scientist in CAMH’s Campbell Family Mental Health Research Institute and Canada Research Chair in Schizophrenia Genetics and Genomic Disorders. “Low birth weight and preterm birth have been proposed as risk factors in schizophrenia in general, but past studies have
not shown a large effect on risk,” says Dr. Bassett, who is also the Director of the Clinical Genetics Research Program at CAMH. “We’ve focused our lens on these risks in a small population with a specific genetic subtype of schizophrenia, where the connection between birth factors and risk of developing schizophrenia is noticeably stronger.” The risk of schizophrenia is known to be high in individuals with 22q11.2 deletion syndrome, as about one in four develops schizophrenia. This study found the risk was even higher – nearly one in two – among those who were born with a low birth weight or prematurely, based on standard measures. The syndrome is caused by a small deletion on chromosome 22. It can lead to heart or palate abnormalities, develop-
mental delays and other physical health problems, and in one in four cases, a schizophrenia diagnosis in late adolescence or early adulthood. “The results needs to be replicated, but do have important clinical implications,” says Dr. Bassett. For instance, there are now prenatal tests that can signal the possibility of a 22q11.2 deletion as early as the first trimester of pregnancy. While such screening requires further confirmation through additional testing, it raises the idea of intervening, in cases where the deletion exists, during pregnancy or immediately after birth. “The big-picture question is whether there is a way to support the developing fetal brain to improve outcomes, and lower the risk of schizophrenia,” says H Dr. Bassett. ■
Canadians are concerned about the long-term care needs of seniors An alarming new poll finds that Canadians are overwhelmingly concerned about the ability of Canada’s long-term care system to care for seniors when living at home is no longer possible. More than nine in 10 Canadians are concerned that patients are waiting too long for placement into longterm care homes; that staffing levels are not adequate; and that there will not be the capacity to provide the level of care needed by seniors with dementia in longterm care homes. The survey also asked Canadians about their confidence in Canada’s long-term care system to care for them in the future, and found that less than two in 10 Canadians in all categories believe that Canada is prepared for the growing needs of seniors who need long-term care, especially those with dementia
When asked to choose between delaying additional investments until government’s budget woes improve or to invest now, almost 80 per cent believe that due to the aging population, we need to invest immediately. Key findings: •When asked to rank the area in health care of most concern to them personally, more Canadians declared long-term care their first or second priority than the other options presented to them. (wait times, mental health, home care, national pharmacare). •93 per cent are concerned or somewhat concerned that patients are waiting too long for placement in a long-term care home. •91 per cent are concerned or somewhat concerned that homes are not being prop-
erly staffed to meet the needs of seniors; •91 per cent are concerned or somewhat concerned about the high level of support needed by seniors diagnosed with dementia. •91 per cent are concerned or somewhat concerned that there won’t be enough long term care beds to the meet the future needs. •Only two in 10 believe there will enough staff to provide care to seniors when they need it. •Less than two in 10 are confident that hospitals and long-term care homes will be to handle the needs of Canada’s aging population. •1.5 in 10 are confident that longterm care homes will be prepared for the rising number of Canadians living with H dementia. ■
Nurses launch digital drive The Canadian Nurses Association (CNA) launched its Health Is Where the Home Is digital campaign for better seniors care and healthy aging, including an interactive website. More than 14 per cent of Canadians are 65 or older – an age group expected to double by 2036. As the election campaign gets underway, CNA wants to draw attention to the significant gaps in seniors home care and the recommendations it has developed for federal leaders. Since last fall, CNA has met with all the major parties to present its strategies for better seniors home care: 1. Establish common standards for home care across Canada 2. Provide more support to family caregivers 3. Improve community and home-based health promotion CNA’s election website (cna-aiic.ca/ election2015) features several interactive tools and resources to help Canadians extend their voice beyond the ballot box. Visitors can share their thoughts on how the federal government could improve healthcare and say what they think Canadians need to age safely at home. The candidate contact tool makes it easy for any user to identify and get in touch with the H confirmed candidates in their riding. ■
Correction In the August issue of Hospital News the photo of Trillium Health Partners’ Interprofessional KidFit Team was incorrect. Hospital News regrets the error.
Be their facilitator to living safely at home Join our team of solutions-driven Care Coordinators Be the health advocate clients count on to shed light on a complex health care system, identify their unique needs, plan their care and facilitate their access to timely, quality care so that they can live safely and independently at home or in the community. RNs, MSWs, OTs, PTs, RDs and SLPs are invited to apply. For details, locations and staff videos, and to apply for a Care Coordinator, Nursing or other role, visit ccacjobs.ca. Most Community Care Access Centres of Ontario are governed by the requirements of the French Language Services Act. We provide services in French and encourage applications from bilingual candidates.
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Hands down – It’s simple and effective
Sunnybrook launches Clean Hands Matter, a new Hand Hygiene initiative By Natalie Chung-Sayers
ould you feel comfortable asking your nurse or doctor if they cleaned their hands? That’s the question Sunnybrook’s Infection Prevention and Control department posed to members of the public. Although all expected their health care provider to clean their hands, most would hesitate to ask. These responses helped in the development of Clean Hands Matter, a new hand hygiene initiative at Sunnybrook aimed at empowering patients and family members while reminding everyone about this simple and effective way to reduce the spread of infection. Clean Hands Matter draws from existing awareness campaigns about the importance of hand hygiene. The Ministry of Health and Long-Term Care launched the Just Clean Your Hands campaign in 2008, and the Ontario Hospital Association launched It’s Okay to Ask, a year later. Sunnybrook was an early adopter of Just Clean Your Hands and made significant improvements in hand hygiene compliance. “Clean Hands Matter reinforces messages with our care teams about the importance of proper hand hygiene practice while making the approach more interactive and geared to patient engagement,” says Dr. Mary Vearncombe, Medical Director, Infection Prevention and Control, Sunnybrook.
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Interprofessional members of one of Sunnybrook’s oncology care units wear their “Ask Me If I’ve Cleaned My Hands” blue buttons. The initiative features signage at the point of care. Table cards inform patients about the key times when hand hygiene should be performed and may also remind health care teams. The cards detail these moments in a conversational way. This empowers patients and families should they choose to ask members of their care team if they have cleaned their hands. For further encouragement, some staff also wear “Ask Me If I’ve Cleaned My Hands” buttons. “Previous awareness campaigns that we developed and implemented here, have helped support a culture of improved hand hygiene compliance,” says Dr. Vearncombe.
Spanning the last seven years, the organization has launched customized campaigns about proper hand hygiene that have created relevance with staff members through peer perspectives, and quantified its importance through citations of published studies. The organization also continues to recognize staff members who perform exemplary hand hygiene as assessed by a trained observer and acknowledge these individuals with celebratory “Caught Clean-Handed” stickers. ”Feedback from patients has been positive about Clean Hands Matter,” says Dr. Vearncombe about the initiative’s pilot tri-
“Our newest members at Sick Kids Hospital know that OPSEU is the union for changing times, and we have the experience that gets results for hospital workers.”
• About one in nine patients get infections each year in Canadian hospitals. • Antibiotic resistant organisms* add $40 to $50 million to annual care costs. *MRSA (methicillin resistant staphylococcus aureus) with an assumed infection rate of 10 to 20 per cent. • Proper hand hygiene is the most effective way to prevent transmission of infection al that was conducted on three acute care units, before it was introduced across the hospital. “A number of patients have told us it’s a good idea because everyone wins.” Feedback from staff is also encouraging. Dr. Jeremy Gilbert, President of Sunnybrook’s Medical-Dental Midwifery Staff Association, says he would never be offended if he were asked about hand hygiene. “I look at it as a relationship I have with patients – that I’m there for them. And if I didn’t wash my hands, I’m actually H doing them a disservice.” ■ Natalie Chung-Sayers is a Communications Advisor at Sunnybrook Health Sciences Centre.
Warren (Smokey) Thomas OPSEU President
als than any other union in Ontario, OPSEU ge hospital profession ts you RESULT e r o m g n i t n e S. Repres
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Reducing planning time for critical patient transfers By Nancy Painter
patient at a rural hospital is critically ill and needs to get to a larger hospital as soon as possible. But there’s more involved than putting the patient in an ambulance and driving away. Sending and receiving physicians, the BC Patient Transfer Network (BCPTN) patient transfer coordinator, clinical transfer nurse, an emergency transfer physician, and the dispatchers within BC Ambulance Service’s Patient Transport Coordination Centre all have a part to play in the decisions about moving the patient. The time it would take to call each of those people is time the patient might not have. However, BCPTN implemented changes in 2014 that decreased the time required between receiving the initial call and having a transfer plan in place from a median of 38 minutes to 11 minutes or less. Part of the Provincial Health Services Authority (PHSA), BC Emergency Health Services includes both BCPTN and the BC Ambulance Service, and is responsible for out-of-hospital and inter-facility care for the entire province of British Columbia, an area of almost 945,000 square km. In August 2013, BCEHS approved a new Patient Acuity for Transfer matrix that uses colours to identify the medical acuity of patients awaiting transfer. By adopting the red/yellow/green/blue matrix for all agencies involved in patient transfer and transport, they eliminated the potential for misunderstanding because of different codes used by different partners.
HOSPITAL NEWS SEPTEMBER 2015
A patient identified as Red has an immediate threat to life, limb or organ and requires immediate intervention. Yellow patients require time-sensitive intervention, Green patients have a scheduled appointment they need to be transferred to, and Blues are routine transfers of a patient for admission to an equal or lower level of care. In the year from November 2012 to October 2013, BCPTN handled 10,189 Red transfers, with more than 900 per month in the peak months of June and July. In December 2013, BCEHS representatives from the BC Patient Transfer Network, Medical Programs, Service Delivery
(Dispatch) and Critical Care Programs collaborated in a week-long rapid process improvement workshop (RPIW) to find a better way to handle Red transfers. The result was a new process in which the clinical transfer nurse coordinates a conference call with all parties involved in the transfer decisions for the patient in question. First, the sending physician, receiving physician, BCPTN emergency transfer physician and clinical transfer nurse consult to confirm that the patient is, indeed, a Red patient. Next, the dispatcher determines appropriate and available resources. With all on the call in agreement, the dispatcher
orders the necessary ambulance, plane or helicopter to set the process in motion. “We were able to create a much more streamlined process by eliminating gaps, strengthening our teamwork and focusing on patient care needs,” explains Kathy Steegstra, senior provincial executive director of patient care communications and planning. “By bringing together the key members of the Red team on the teleconference, we were able to dramatically reduce the time from when the call comes into the call centre to when we have an agreed-upon transfer and transport plan in place.” “The new process that launched in March 2014 improved results immediately,” Kathy says. “We improved collaboration, and our lead time decreased from a median of 38 minutes to 17 minutes during our pilot in the call centre. “By the time we went live in March 2014, our lead time was consistently 11 minutes or less. That’s a 72 per cent reduction in lead time, creating a huge difference in the level of patient care that BCEHS can provide.” The improvements have not gone unnoticed. Kathy Steegstra presented on the processes and their results at the Western Emergency Departments Operations Conference, involving professionals from the four western provinces. Kathy Steegstra sums up their work, and their success, quite simply. “Ultimately, we are improving patient care as a reH sult of excellent teamwork.” ■ Nancy Painter is an Internal Communications Officer at BC Emergency Health Services.
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Innovation in paediatric emergency care
improves patient experience By Denise Hudson
n innovative approach to emergency care at BC Children’s Hospital in Vancouver is reducing inpatient admissions, improving flow in the emergency department (ED) and saving health care dollars. An initiative of the Provincial Health Services Authority, the construction of the new Teck Acute Care Centre (TACC) is currently underway and scheduled for completion in late 2017. The TACC is the second phase of a three-phase BC Children’s and BC Women’s Hospital Redevelopment Project. The majority of the inpatient programs and units located in the current facilities will move into the new hospital in late 2017, including the paediatric ED. The
new hospital will mean more clinical space, 231 private, single-patient rooms, amenities for patients and families, better integrated technology and equipment and an improved healing environment. But care providers are not waiting for the TACC to open its doors to explore opportunities to enhance patient care and are initiating improvements to the delivery of healthcare now. A core team of care providers from the emergency department – including physicians, nurses and pharmacists – worked closely together to plan and test pilot a four bed clinical decision unit (CDU) within the existing ED in late 2014. A CDU is defined as a distinct area where patients from the ED are formally assigned on a short-term basis following
FRIENDS AND COLLEAGUES IPAC Canada is a multidisciplinary professional association of those engaged in the prevention and control of infections in all healthcare settings. IPAC Canada represents its members in the pursuit of patient and staff safety and in the promotion of best infection prevention and control practices. We work regularly with other professional associations and regulatory bodies to develop guidelines. Our members come from across the continuum of care. Visit our website www.ipac-canada.org to see the many benefits and resources that are available to members.
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Emergency department staff at BC Children’s Hospital in Vancouver (from left to right): Dr. Paul Enarson, Catherine Merten, Cheryl Stevenson and Sarah Cummins. initial triage and assessment. CDUs have been designed for adult patients with success, but the concept was relatively new to paediatric emergency care. These are patients that require additional monitoring, investigation, and treatment prior to a decision to transfer to another area of the hospital or to discharge home. The benefits of a CDU include: • More efficient patient flow within the ED • Reduced inpatient admissions from ED • Reduced length of stay • Improved patient and family satisfaction • Improved clinical outcomes • Standardization of care • Effective, safe and efficient care • Reduced health care costs Established criteria for CDU patients exist for adults, but not for children and youth. Challenged with this, the dedicated team of care providers established and tested their own inclusion/exclusion criteria for transfer to the CDU. The pilot found that asthma, reactive airway disease, croup, gastroenteritis and head injuries were the top patient-visit reasons for transfer to the CDU.
A Clinical Decision Unit (CDU) is defined as a distinct area where patients from the ED are formally assigned on a short-term basis following initial triage and assessment. Initially, the CDU team faced some challenges in getting care providers to adopt the CDU concept, but continued communication, staff training and, ultimately, the data soon won them over. The CDU trial ran over a period of six months, and there were no admissions from the CDU to the paediatric intensive care unit and no adverse patient safety events were reported. The CDU diverted 157 patients who could have otherwise been admitted to an inpatient unit in the
hospital and stayed two to three times longer. In total, 947 patients were transferred to the CDU, helping to improve patient flows, freeing up clinical care spaces to assess other patients in the emergency department and contributing to overall cost avoidance. A staff survey also found that care providers felt they were better able to provide quality care overall, and those working in the inpatient units felt they had more time to focus on sicker inpatients. Patients and families reported that the CDU improved the quality of their care during their ED visit. Many of the families of patients transferred to the CDU say the quieter environment helped reduce overall stress and contributed to faster recovery or healing. They also appreciated avoiding an inpatient admission and being discharged home as soon as their child’s condition improved. “When I bring my son in for an asthma problem, we stay for long periods in the main department, sometimes up to 12 hours,” says a parent of a two-year-old patient. “During our stay this time, we were quickly transferred to the new CDU and my son actually slept, because it was a much calmer environment. We were cared for by one nurse. Everything was excellent – treatment, communication and discharge instructions from the nurse.” The ED is the busiest department at BC Children’s Hospital, seeing over 43,400 patients last year alone. When the TACC opens, a six-bed CDU will be located within the new ED, which will be three times larger than the current one. Each CDU patient room will include private bathrooms, nourishment stations and patient entertainment, all within an aesthetically pleasing, healing environment. In the meantime, while the TACC construction is underway, the proactive, innovative thinking of care providers combined with the dedication to deliver the highest possible quality of care is making a positive difference right now to patients and H families. ■ Denise Hudson is Clinical Lead, Emergency Department, BC Children’s Hospital. www.hospitalnews.com
Data Pulse 11
A snapshot of injury data for Canada By Greg Webster
rauma and the emergency department (ED) are inexorably linked. Many sufferers of trauma – particularly the most serious traumas – will be treated at their nearest ED or trauma care centre. These are two topics that the Canadian Institute for Health Information (CIHI) has produced several reports on owing to the crucial knowledge gap it fills and the strategic planning benefits of providing a timely, relevant and actionable snapshot of trauma hospitalizations and ED visits in Canada. An estimated 17 million visits are made to the emergency department across Canada each year. Based on Ontario and Alberta, the jurisdictions for which complete ED data is available, approximately 22 per cent of these visits are due to injuries. What makes examining trauma data so important is that it can provide a greater understanding of injury rates and volumes, contribute to clinical science and research on trauma management, and be used to develop effective injury prevention programs.
These databases provide valuable insight on volumes and types of cases presenting to Canadian emergency departments and being admitted to acute hospitals. In total, CIHI has built and maintains 28 pan-Canadian databases that enable health facilities, health regions, ministries of health, clinical and academic researchers to use and compare data. Those stakeholders can then apply this information for resource and service planning, policy decisions and research provides valuable insight on volumes and types of cases presenting to Canadian hospitals. This is, of course, just one sample of
the data CIHI collects and shares. CIHI data also helps long-term care facilities reduce the use of antipsychotic meds for seniors, and hospitals rethink traditional models of care for homeless people, just as examples. CIHI continues its important mandate of informing health system decisions on a myriad of topics, always in service of our vision: Better data. Better decisions. H Healthier Canadians. ■ Greg Webster is Director, Acute and Ambulatory Care Information Services at the Canadian Institute for Health Information.
Emergency Services in CIHI Data Last fall, CIHI released data on potentially avoidable ED visits. That data illustrated not only that 1 in 5 ED visits was potentially avoidable, but also treatable in a different setting, like a family physician’s office. This kind of insight can go a long way towards improved planning and changed behaviour. CIHI is constantly working towards that next update, ensuring the most timely information is available. In fact, ED quick stats for 2014-2015 will be available on cihi.ca before the calendar flips over to 2016. Our work is designed to benefit the health care system, by allowing ED resources to be focused on those who need them most.
What’s new? Our latest release of Injury and Trauma Hospitalization and Emergency Department Quick Stats provides new age and gender breakdowns for sports and winter injuries. It notes some interesting changes in injury rates for 2013–2014 compared to the year before: • The number of hospitalizations caused by falls on ice increased by 44 per cent for males (from 3,235 to 4,668) and 37 per cent for females (from 3,983 to 5,471) in 2013–2014, compared to 2012–2013. • Sports injury hospitalizations declined three per cent overall (from 19,568 to 18,909) from 2012–2013 to 2013–2014. • There was a seen per cent increase in ED injury visits by seniors aged 65 and older. The statistics above represent a small snapshot of injury and trauma hospitalizations and ED visits in Canada. You can check out the entire set of data tables in CIHI’s Quick Stats page (www.cihi.ca/ quick-stats) for more in-depth data.
Why does CIHI compile this type of information? CIHI’s work is based on the development and maintenance of comprehensive and integrated health information that contributes to sound policy, effective health system management and hopefully improved health and healthcare. We work with our stakeholders to create and maintain a broad range of health databases, measurements and standards. We also help them understand how to use our evidence-based insight and analyses in their day-to-day decision-making. We develop reports and analyses from our own data and other data sources. CIHI does all of this in a way that ensures privacy and value for Canadians and our health care systems across the country.
Where does CIHI’s data come from? This data is developed using CIHI’s Discharge Abstract Database (DAD), Hospital Morbidity Database (HMDB), Ontario Mental Health Reporting System (OMHRS), and National Ambulatory Care Reporting System (NACRS) databases. www.hospitalnews.com
SEPTEMBER 2015 HOSPITAL NEWS
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Stroke care on wheels saves time and brains Canada’s first stroke ambulance gives best chance for recovery
Canada’s first stroke ambulance — complete with a CT scanner, clot-busting drugs and the potential to cure a stroke before the patient even reaches hospital — is being developed thanks to the University Hospital Foundation’s major investment in the advancement of brain care at the University of Alberta Hospital.
By Gregory Kennedy
orna Friess knows personally and all too painfully that time is brain when it comes to treating a stroke. The 43-year-old suffered a stroke alone in her rural home at South Cooking Lake (east of Sherwood Park in Alberta) in 2013. By the time her fiancé came home hours later, the damage had been done – she had lost the use of half of her body. Early intervention could have made a huge difference in her outcome – and that’s why Friess says she’s thrilled to speak up now about a new approach that promises to bring hospital diagnostics promptly to patients like herself. Canada’s first stroke ambulance – complete with a CT scanner, clot-busting drugs and the potential to cure a stroke before the patient even reaches hospital – is being developed thanks to the University Hospital Foundation’s major investment in the advancement of brain care at the University of Alberta Hospital. “The difficulties I face as a result of my stroke are massive,” says Friess. “Every day life takes so much effort. This project will save so many lives – and save so many people from facing the challenges I face. It is such a huge advancement for stroke care,” she says. The total cost of the stroke ambulance – $3.3 million – will be funded by donors to the University Hospital Foundation. “Its purpose is simple,” explains Dr. Ashfaq Shuaib, Director of the Stroke Pro-
Stroke patient Lorna Friess praises the new stroke ambulance currently being designed and built. gram at the University of Alberta Hospital. “Rather than waiting for the patient to go to the stroke centre, we send the stroke centre out to the patient. “We can scan the patient’s brain and start clot busting drugs right there in the ambulance. Reducing the door-to-treatment time is critical in saving the patient’s life and limiting their disability. We can actually cure them of the stroke.” The stroke ambulance is being customdesigned to meet the unique needs of Edmonton’s environment and service area.
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And it is breaking new ground: the stroke ambulance at Alberta Health Services’ (AHS) University of Alberta Hospital will be the first CT mobile stroke unit in the world to provide stroke patient care beyond the limits of a major urban centre. As part of a three-year clinical research project, researchers will study in detail its impact on patients’ treatment and recovery as well as savings to healthcare and the community. “The time for this project has come,” adds Dr. Shuaib. “The outcomes of stroke are devastating, but the advancements in treatment have come so far in the last few years, and even months. We have the opportunity to get that treatment into the community; to where patients are.” Extending stroke care into rural areas is significant, because nearly 25 per cent (313) of the more than 1,300 stroke patients who received acute stroke care at the University of Alberta Hospital in 2014 came from beyond the Edmonton Zone. “The further you live from a centre that can give clot-busting drugs for a stroke caused by clotting, the greater the chances that you’re going to suffer major disability in a life-changing way, or die,” says neurologist Dr. Tom Jeerakathil, who serves as Northern Stroke Lead for the provincial Cardiovascular Health and Stroke Strategic Clinical Network. About two million brain cells are lost each minute after a stroke. Losing brain cells isn’t the only challenge; doctors need to know what kind of stroke you’re having to provide life-saving care. An ischemic stroke happens when a blood vessel (artery) supplying blood to the brain becomes blocked by a blood clot. About 80 out of 100 strokes are ischemic strokes. A hemorrhagic stroke happens when an artery in the brain leaks or bursts (ruptures). The only approved treatment for isch-
emic strokes is tissue plasminogen activator (tPA), a clot-busting drug that improves blood flow to the part of the brain being deprived of blood flow. But if tPA is given to a patient suffering a hemorrhagic stroke, the results can be deadly. And since the treatment window for stroke is counted in hours, Doctors need to identify the type of stroke quickly – and definitively – to save critical brain cells. In the new stroke ambulance, a radiology technologist will join the two paramedics that ride in a standard ambulance. A fully operational CT scanner will be mounted in the unit, which will also be equipped with audio and video equipment so the attending stroke neurologist at the University of Alberta Hospital will be able to see and speak to the patient in the ambulance. If the stroke neurologist confirms the patient is suffering from an ischemic stroke, they will be given tPA in the ambulance. The goal of the stroke ambulance is to shorten the time between the onset of stroke and the delivery of clot-busting drugs – giving more Albertans suffering from stroke the chance to recover – and to live without life-changing deficits. “This is a novel way of treating stroke patients,” adds Dr. Ashfaq Shuaib. “And my colleagues all over the world are already asking us to share our results once the project is completed.” For her part, Friess has worked very hard at her rehab for the past two-and-a-half years, and has regained her mobility and much more – yet she still hopes to return to her passion for running marathons again in the not-too-distant future. “Hopefully there will be a lot less disability out there, and a lot less problems H for everybody.” ■ Gregory Kennedy is a senior writer at Alberta Health Services. www.hospitalnews.com
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SEPTEMBER 2015 HOSPITAL NEWS
“Scrublics”: One more contribution to the debate By Kevin Reel
crublics have irked me for years. That’s my term for scrubs worn in public. You may have been aware of a few debates – heated, at times – in various media about the practice of wearing scrubs in public. Some quick online searching will take you to them. I absolutely understand that not all scrubs are created or soiled equally – O.R. scrubs are a different thing to those worn by a receptionist or out-patient clinic staffer. But how does anyone else know where your scrublics have been? The reasons offered for wearing them out of the clinical environment include convenience, looking cool and a sense of status. I think I can understand the convenience…who couldn’t? A few minutes saved at the start and end of the working day/night by not having to change into or out of street clothes. A few more minutes saved every time one dresses for work – no need to think about wardrobe. I must confess, though, I don’t get the aesthetic lure – apparently many who choose to sport scrublics feel they are cool, carry some sort of status, or suggest one lives according to one’s own rules (a variation on the status thing). Perhaps I still associate all hospital uniforms with the white
HOSPITAL NEWS SEPTEMBER 2015
tunic and green polyester trousers I used to wear as an OT in hospitals in the UK. I could seldom get out of them fast enough. These debates usually centre on the very little hard evidence of infectious agent transmission. While there may be little conclusive evidence re: scrubs, there is some evidence that neck ties are vectors of infectious nastiness. That might extend support to banning lanyards, too, in favour of retractable shoulder level ID clips. Why wouldn’t those badges get mucky? There is also at least one study indicating home laundered scrubs carried more of those nasties than scrubs laundered by the hospital laundry service. I’ll happily accept that the jury is out on the infection transmission front. But it’s not the evidence of scrublics-related infection that leaves me with a ‘yuck factor’ when I see them – in grocery stores, on the subway, in restaurants and, yes, in the hospital cafeteria. My primary objection to scrublics is the message they may convey, one that conflicts with other messages hospitals aim to convey. We generally try to impress upon people that hospitals require high vigilance around infection control – hand washing obviously, but also contact and other
precautions that are in place at times on whole units or around individual patients. I recall a number of occasions when it was a complex undertaking to enable visitors to understand the importance of these precautions. Is it beyond the pale to suggest that if there were a practice and policy of no scrublics it might reinforce the notion?
While there may be little conclusive evidence re: scrubs, there is some evidence that neck ties are vectors of infectious nastiness. Another message often conveyed is how ‘dangerous’ the hospital is, in general, from the standpoint of infectious diseases and vulnerable patients – especially when someone is designated ‘alternate level of care’. It has become typical to emphasize the array of bugs that might prey upon someone waiting in hospital for their pre-
ferred place to come up in the community. I would argue that among the approaches I have known to be employed to implement the ‘Home At Last’ programs, the concern about hospital-acquired infections might be one of the most defensible in every case. It might serve multiple aims, then, to worry less about the hard evidence of risk of infection via scrublics, and consider the potential benefits of the optics and behavioural modelling if scrubs disappeared from view outside the hospital, and even in those more public places within, such as the cafeteria. I do understand that many of the scrublics aficionados spied at Metro or a neighbourhood Firkin pub may not be hospital staff. If hospitals were to ban scrublics it would at least mean not seeing staff walking in and out of cafeteria, hospital or parking lot wearing them. In the end, aside from some minimal convenience to some staff and perhaps some odd ego boost, what would actually be lost if we were simply to say no to H scrublics? What might be gained? ■ Kevin Reel is Assistant Professor (Status), Dalla Lana School of Public Health, Member, Joint Centre for Bioethics, University of Toronto.
A PATIENT’S PERSPECTIVE
Digital records and patient choices By Alexa Thompson
his fall the Nova Scotia provincial government plans to roll out a digital health records system, known as Personal Health Records or PHR. I’ve been privileged to be involved in the pilot project for the last couple of years. It has allowed me to book online appointments with my family doctor, to access my test results, to keep track of my medications, specialist appointments and a host of other details. I can watch my blood pressure and keep a sharp eye on my weight and body mass index. This past April, however, I ran into a situation I could not have handled as well without digital access to my medical records. I was diagnosed with grade 2 uterine cancer and my gynecologist wanted me to have a hysterectomy as soon as possible to prevent spread of the disease. From that initial diagnosis, things moved rapidly. I saw a gynecologist/oncologist surgeon within days, and he confirmed the diagnosis. Then I was booked for the operation at the end of April. The week before the scheduled date I attended a pre-op clinic and did the usual blood tests, heart monitor, chat with the anesthetist, and so on. The last call was a chest x-ray; then I was free to go. Before I got home, my phone was ringing. The x-ray indicated an enlarged heart and I was quickly scheduled for an echocardiogram the following Tuesday. On the Monday, my worried family doctor called me in as she had just received the x-ray, to tell me I would probably be seeing a cardiologist before the operation, now only three days away. She also expressed surprise at the x-ray results given that I am a resistance weight trainer.
This fall the Nova Scotia provincial government plans to roll out a digital health records system, known as Personal Health Records or PHR. On Tuesday I had the echocardiogram. Late Wednesday I received the digital results from my doctor. No time for a personal consultation as I was due in the operating room the next morning. I read them and realized the results were within a normal range. It suggested the x-ray had been an anomaly but I’m not a medical professional. Thursday morning, well before 8 a.m., as I lay on a gurney, prepped for surgery, the anesthetist dropped by. He had the echocardiogram results but he also wished I’d had time to see a cardiologist before the operation. He’s confident there won’t be a problem but he wants me to be aware of the risks and decide for myself if I want to go ahead. On the one hand I have cancer. On the other, I might experience heart failure during surgery. That is one hell of a decision to be asked to make moments before being wheeled into the O.R. But I had read that echocardiogram. I understood the results. I wasn’t just takwww.hospitalnews.com
ing the anesthetist’s word for it; I knew the best choice was to go ahead and eradicate the cancer before it grew worse. That confidence in a very tricky situation came about solely because my doctor and I were involved in the digital health records pilot and I had had an opportunity to read and understand my test results within the privacy of my own home. I realize many patients might not want to deal with test results or feel unsure about understanding results without a physician’s assistance. I appreciate that.
I’m sure there are doctors too who worry about patients struggling to interpret results on their own. The important thing is I was given a choice. I chose to read that report. I chose to trust my own opinion as well as that of the anesthetist. Others may have chosen differently. I was lucky. I came through the surgery and have been assured the cancer is gone. I did see that heart specialist. A letter with the appointment time and date awaited me when I got home from hospi-
tal. It came through regular snail mail. Do you know what are the odds, if you live in a large apartment complex like I do, of a letter being accidentally misplaced in the wrong mailbox? The heart surgeon confirmed everything was fine. Just don’t lift 100 lbs. weights, he cautioned. I’m 67. I don’t H think that’s going to be a problem. ■ Alexa Thompson is a freelance writer and editor with an interest in patientcentred healthcare.
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Is Canada’s nursing supply set to shrink? By Diana Swift
f there’s truth to the saying “Doctors diagnose, nurses heal, then a recent report of the first drop in Canada’s regulated nursing supply in almost two decades could be cause for alarm. According to the Ottawa-based Canadian Institute for Health Information (CIHI)’s Regulated Nurses, 2014, released June 23, last year saw a small 0.3 per cent fall nationally over 2013 in those holding active nursing licences (the “regulated supply”) and one per cent fall in the supply of registered nurses, the backbone of the public-sector nursing workforce. Nationally 27,757 nurses let their oneyear licences lapse at the end of 2013, while just 25, 397 registered in new jurisdictions. Almost 45 per cent of the national drop, says Andrea Porter-Chapman, CIHI’s manager of health workforce information, was due to a new regulation in Ontario, the province with the largest nursing pool and the second worst ratio of RNs to population. It stipulated that nurses could renew licences only if they had actively practised in Ontario within the past three years. That change may be driving what amounts to just a one-year aberration, says Porter-Chapman, but “it’s something to keep an eye on since it’s the first shift we’ve seen in 20 years.” Fortunately, the current active nursing workforce remains stable and robust but that could quickly change. With reports of more licensed nurses leaving than entering in 2014, 25 per cent of nurses nearing the traditional 58-ish retirement age and the average age of nurses holding steady at about 45, on-the-ground resources could soon be threatened. With potential attrition on the horizon, warn experts, Canada needs to keep a steady hand on the nursing supply tiller. “Human resources planning is forever planning. It’s not just a response to a blip on your radar,” says Linda Silas, RN, president of the Canadian Federation of Nurses Unions (CFNU) in Ottawa. She adds that owing to health care reform cutbacks in the 1990s, Canada is “missing a whole generation of experienced nurses” who would now be at the top of their game. Another red flag in CIHI’s report was the slowing growth rate of new nursing graduates, which dropped from a range of six to 12 per cent over the
Nursing snapshot 2014 Total nursing supply ................406,817 Registered nurses .................. 289,239 Nurse practitioners .....................3,966 Registered psychiatric nurses ...5,689 Licensed practical nurses ......107,923 Net loss of nurses from 2013 ....2,360 Drop in RN supply from 2013 ......... 1% Source: Canadian Institute for Health Information, Regulated Nurses, 2014
Canadian cross-border RN Samrinder Sahota, 22, a 2104 graduate of the University of Windsor who enters the U.S. every day to work at Beaumont Health’s Oakwood Hospital in Dearborn, Michigan. Photo credit: Samrinder Sahota. past five years to below one per cent. The still-iffy economy, ushered in by the 2008 recession, has a lot to do with that. “Admissions to nursing schools are surprisingly sensitive to employment opportunities,” says Cynthia Baker, PhD, executive director of the Canadian Association of Schools of Nursing. “Our graduates are not flying into jobs, and many of them juggle part-time employment for several years before finding permanent positions.” For the past two decades, nursing resources in Canada have been on a cyclical roller coaster of under- and over-supply as health ministries cut back or beefed up funding for nursing education and employment. “There’s simply no planning, says Silas, who was not surprised by the CIHI figures. “How is it that a quarter of our nurses could retire tomorrow and yet when you talk to new grads, they can’t get full-time jobs?” Some, she adds, turn to stop-gap employment in other sectors from real estate to pharmaceutical companies while awaiting positions, “but that’s dangerous because if you don’t keep your clinical skills up, how can you be an efficient nurse?”
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Others opt to go stateside where a shortage of nurses means more opportunity for full-time and specialized work. In a braindrain coup at a July 2015 job fair in Windsor, Ontario, 54 Canadian-taxpaer-trained nurses were snapped up by Detroit’s Henry Ford Hospital, which currently employs about 220 Canadian RNs. One Canadian cross-border RN is Samrinder Sahota, 22, a 2104 graduate of the University of Windsor who enters the U.S. every day to work at Beaumont Health’s Oakwood Hospital in Dearborn, Mich. “I chose to go a U.S. hospital because I was could get full-time work in specialized care – plus they would train me better,” says Sahota, who underwent 12 weeks of specialized instruction before joining Oakwood’s’ intermediate intensive-care unit. The best he could hope for in Ontario was part-time general nursing. Would he prefer to work in Canada if full-time work came up? “No, I would stay where I am,” says Sahota, even though the rate of pay is slightly lower. For him, a major factor is the culture of respectfulness at Oakwood, something he found lacking when he did his practical training in Ontario hospitals. “Here on the unit they value the opinions of a new staff member. They treat you respectfully like a colleague, not a new arrival, and that makes a big difference to the retention of nurses.” Increasing numbers of new grads may be thinking along similar lines. In research at the University of Windsor led by nursing professor Michelle Freeman, PhD, the proportion of graduating nurses considering leaving Canada to work rose from 66 per cent in 2011 to 71 per cent in 2013. Silas thinks the pace of the US-bound trend may quicken as Obamacare extends American medical coverage and ramps up nursing needs. And potentially easing the cross-border flow is that as of January 2015 Canadian and American nursing students write a very similar national exam, the NCLEX-RN, administered by the same U.S. testing organization. Even in the setting of permanent, fulltime employment, the Canadian health
care workplace can be anything but healthy for nurses. According to Silas, nurses face more violence, erosion of professional respect and autonomy, inflexible schedules, heavy workloads and increasing burnout. A 2015 CFNU report revealed that in 2014 nurses worked more than 19 million hours of overtime, 22 per cent of it – almost $200 million – pro bono. “Overtime contributes to excessive workloads and high levels of absenteeism, which erode patient care,” says Silas. According to the CFNU survey, 30–40 per cent of nurses reported experiencing post-traumatic stress disorder symptoms, and 2014’s absenteeism rates rose a few basis points over 2012’s to 7.9 per cent, for a systemic cost of about $846 million a year. Similarly, in a 2103 CBC online poll of Canadian nurses, 40 per cent reported burnout, and many said belt-tightening measures such as not calling in substitutes for sick nurses were threatening patient care. And almost two-thirds said inadequate staffing was preventing them from doing a proper job of delivering quality care. According to the Canadian Nurses Association, serious shortfalls are looming and existing shortfalls are being masked by overtime and delayed retirements. The human resources management of nurses – who make up a third of healthcare workers – will become more urgent as our growing population ages and demands for care increase and diversify. “Looking ahead it’s a very complex portrait, with increasingly diverse nursing needs,” says Baker. “In addition to acute-care hospital-based nurses, society will need more communityand home-based nursing services.” What’s needed is a longitudinal strategy, a prospective plan. “If you don’t plan ahead, you’ll get periods where you have to pay enormous sums of money either to retain the existing experienced workforce or recruit from elsewhere,” says Silas. “If you H plan, you won’t have to do that.” ■ Diana Swift is a freelance writer. www.hospitalnews.com
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Customized training helps rural doctors meet emergency medicine needs By Riannon John
t began with coffee. Five emergency medicine physicians sat down on a cold January day to discuss the chronic shortage of access to emergency care in rural Ontario and consider what they could do to address the growing issue. By the time they finished their drinks, they had a vision for a program to train practicing physicians in smaller communities in a wide range of emergency medicine skills. That vision became the Supplementary Emergency Medicine Education program, based at Mount Sinai Hospital. “We saw an opportunity to share our expertise and resources with colleagues in smaller centres by providing practical and relevant training, enabling our learners to better meet the diverse needs of their patients and communities,” says Dr. Howard Ovens, Chief of Emergency Medicine at Mount Sinai Hospital, part of Sinai Health System. As the Ontario Provincial Expert Lead in Emergency Medicine, Dr. Ovens is uniquely positioned to understand the challenges and opportunities facing this sector. Dr. Ovens founded the program with Drs. Shirley Lee and John Foote, part of his team at Mount Sinai Hospital’s Schwartz/Reisman Emergency Centre, and former Sinai colleagues Drs. Eric Letovsky, now Chief of Emergency Medicine at Trillium Health Partners, and Tim Rutledge, now CEO of North York General Hospital.
Offering professional training This practical training program is the first and only one of its kind in Canada. Created in collaboration with the University of Toronto’s Department of Family and Community Medicine led by Dr. Lynn Wilson, and the Ontario Ministry of Health and Long Term Care, it recently received five years of funding from the Ministry fol-
A simulation training session is part of the Supplementary Emergency Medicine Education program, based at Mount Sinai Hospital. lowing a highly successful three-year pilot. Practicing physicians join an intensive 12-week program with training in many areas of emergency medicine. Through academic seminars with leading experts, workshops, simulations, mentorship, and hands-on training, participants get a practical education that prepares them for the needs of their community. Currently, some 350 teaching faculty conduct this training at 13 Ontario hospital sites. This preparation is supported by 90 free, open access elearning modules, which have been visited by thousands of physicians from around the world since their launch. “Many Canadians live in rural or semirural areas, and those communities need emergency medical care,” says Dr. Lee,
Education Director for the Department of Emergency Medicine at Mount Sinai. She heads the program, developing all aspects of the curriculum and working closely with learners to ensure their success. She also keeps in touch with past participants to follow their progress. “This is a real, longterm solution to meeting those needs and building capacity – our graduates are now providing top-notch care in over 45 communities across the province.”
Spreading success The program’s success has generated interest from across Canada and around the world. Dr. Lee is now collaborating with colleagues at the University of British Columbia to establish a similar program there.
The 39 graduates of the pilot program are quick to sing its praises, including Dr. Christine Pun, an Emergency Physician in Sudbury, Ontario. Dr. Pun works at Health Science North, the only hospital in Sudbury. Formerly a family doctor, she wanted to upgrade her skills and improve her confidence in her new role. As part of the emergency medicine team at this important regional hospital, she’s often called on to handle a wide range of acute emergencies. “Because I’d been practicing medicine for a while and had emergency experience, I wasn’t sure that I would gain much from the program,” says Dr. Pun. “But I was amazed – I got a lot out of it, really valuable tips that I use every day. And now I’m passing that information along to my learners.” Dr. Pun was particularly impressed with the high quality of the instruction, the practical nature of the training and how customizable the program was, with each participant working toward individual goals to meet their own – and their patients’ – needs.
Delivering care in the community “By offering targeted and effective training to give them competence in emergency medicine, we’re helping local doctors give their patients the care they need, where they need it,” noted Dr. Lee. The program is expanding, partnering with the Northern Ontario School of Medicine to provide even more diverse training opportunities for participants. “I’m very proud of what Dr. Lee and her team have achieved so far with the Supplementary Emergency Medicine Education program, and what is yet to come,” says Dr. Ovens. “I look forward to spreading this initiative, sharing the expertise and experiH ence we have developed.” ■ Riannon John is a Senior Specialist, Media Relations at Mount Sinai Hospital. HOSPITAL NEWS SEPTEMBER 2015
Legal Update 19
Duty to protect hospital staff from workplace violence is paramount By Michael Watts and David Solomon
he Government of Ontario recently announced that it is establishing a “Workplace Violence Prevention in Health Care Leadership Table” to “better protect health care professionals on the job.” This announcement follows last year’s decision by the Ministry of Labour to lay charges under the Occupational Health and Safety Act (OHSA) against a public hospital for failing to take “every precaution reasonable in the circumstances” for the protection of staff from violent patients. If convicted, the hospital could face a maximum fine of up to $500,000. With the above context in mind, we briefly review below how, under the OHSA, hospitals, including their directors, officers and supervisors, owe an elevated precautionary duty of care to protect staff that is paramount to the duty of reasonable care owed by hospitals, and their directors and officers, to patients under the Public Hospitals Act (PHA). Although the courts have not (yet) considered the precautionary standard of care in the context of the paramountcy of the OHSA over the PHA, hospitals can anticipate that these arguments will be made in any litigation brought by the Ministry of Labour alleging a failure to protect staff.
Under the PHA’s Hospital Management Regulation, hospital boards must establish procedures under the bylaws for (i) a safe and healthy work environment in the hospital; (ii) the safe use of substances, equipment and medical devices in the hospital; (iii) safe and healthy work practices in the hospital; (iv) the prevention of accidents to persons on the premises of the hospital; and (v) the elimination of undue risks and the minimizing of hazards inherent in the hospital environment.
Hospitals as employers, along with their supervisors, owe specific duties of care to take “every precaution reasonable in the circumstances for the protection of a worker. Although hospital directors are protected from liability for carrying out their duties under the PHA in good faith, the protection can be lost when directors act in bad faith. Notably, there is no corresponding protection from liability under the OHSA. The Ontario Court of Appeal has stated that directors will be found to have acted in bad faith where the board has exercised
its statutory decision-making function for an ulterior purpose – and not for the public good – in circumstances where it had to know that its conduct would likely injure others (see Rosenhek v Windsor Regional Hospital, 2010 ONCA 13). Under the OHSA, hospital directors and officers have a general duty to take reasonable care to ensure that the corporation complies with (i) the OHSA and the regulations; (ii) orders and requirements of inspectors and directors; and (iii) orders of the Ministry of Labour. Hospitals as employers, along with their supervisors, owe specific duties of care to take “every precaution reasonable in the circumstances for the protection of a worker.” In light of the general duty to ensure compliance with the OHSA owed by directors and officers, it is arguable that they too owe these specific precautionary duties to staff. At least once a year, the measures and procedures for the health and safety of workers must be reviewed and revised in light of current knowledge and practice. The review and revision of the measures and procedures must be done more frequently than annually if (a) the employer, on the advice of the joint health and safety committee or health and safety representative, determines that such review and revi-
sion is necessary, or (b) there is a change in circumstances that may affect the health and safety of a worker. As noted above, the OHSA expressly provides that its provisions prevail over any general or special Act in Ontario (including the PHA): 2.(2) Despite anything in any general or special Act, the provisions of this Act and the regulations prevail. [emphasis added] It is therefore clear that the duty of care owed by hospitals to protect staff under the OHSA is paramount to the duty of care owed by hospitals to patients under the PHA. This paramountcy, when considered in light of use of the word “precautions” in the OHSA, suggests that the precautionary principle must guide hospitals in ensuring that staff safety concerns are taken seriously, and that staff are made to feel safe, even if that means implementing or continuing heightened safety precautions that some experts may argue are not proven as being necessary. Accordingly, hospitals must be prepared for circumstances where competing duties may require hospital boards to prioritize staff safety above patient care in developing or approving policies under the business judgement rule. Continued on page 20
SEPTEMBER 2015 HOSPITAL NEWS
EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
Evolving critical care –one nurse at a time By Chris Burden
t’s 2:30 a.m. in the ICU and things are settling down – but I know that can change instantly. Whether it is a STAT admission from the emergency department or a Code Blue on one of the units, the ICU can change in a heartbeat. This happened to be one of those nights. A Code Blue was called from the medicine unit. I respond to the code, running down the hall, running through what I will need to do when I arrive in the room and what my role will be in the care of this patient. I am running toward the unit where I started my nursing career seven years earlier.
As ICU nurses, there are many characteristics we share. One is the penchant for managing high pressure, high stakes situations. After the code was over, the outcome sadly unsuccessful, I walked back to the ICU and started thinking about where it all began. I thought about how my role as a nurse had evolved, and is continually changing. I reflected on the changes Markham Stouffville Hospital has gone through, including a major expansion that doubled the size of the hospital and brought many new staff to our units. I thought about the nurses at MSH and how
they embrace different roles beyond bedside nursing and the huge role nursing staff played in the expansion. Just like the growth of MSH, my own career has taken me on an interesting path. Starting out as a bright eyed, excited – and sometimes scared – rookie nurse among experienced individuals was a daunting but valuable experience. Caring for patients on a busy medicine/telemetry unit enabled me to gain broad experience quickly. I learned numerous valuable lessons and within a year I had acquired many new qualifications. It soon became clear to me that I wanted to work in critical care so I used my break times to meet with ICU staff and learn whatever I could in the short time available. My colleagues thought I was crazy to spend my breaks there – but I saw it as an opportunity to better my knowledge, and ultimately, my practice on the medicine unit. As my career progressed, I learned that nurses take many different paths. For some, they remain committed to bedside nursing and feel their greatest contribution is in continuing to care for patients every day, right at the bedside. For others, they see bedside nursing as an integral part of their career but also look for other ways to contribute to the field of healthcare. I continue to be impressed by my colleagues who donate time and expertise to contribute toward making a difference in healthcare beyond their job-specific responsibilities. Many colleagues of mine are integral parts of hospital committees tasked with improving patient experience. Nurses bring a fresh perspective to this area – that’s why I am involved in various committees in-
Chris Burden, RN, in front of the new main lobby at Markham Stouffville Hospital. Nursing staff played an important role in planning the hospital’s expansion and renovation. cluding the Code Blue response team and the TGLN (organ donation) committee. I have participated in many special projects and like my colleagues before me, the chance to improve patient experience and outcomes are my top priorities. As ICU nurses, there are many characteristics we share. One is the penchant for managing high pressure, high stakes situations. We’re Type A personalities and we know it. This led me into teaching as I believe the role is critical to the future development of qualified and well trained nurses. I felt the best way for me to contribute to the future of healthcare would be to share my learned experience and expertise with the next generation of nurses. My first teaching role was when I was responsible for a nursing consolidation student. It reminded me of where I was only a few short years prior and how much, and how fast, new graduates can learn. I knew it was something I would eventually want to do more of, so I jumped at the chance to secure a position with George Brown Col-
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HOSPITAL NEWS SEPTEMBER 2015
lege’s acclaimed Critical Care Certificate program. I became the clinical instructor for students assigned to the hospital’s med/surg ICU. Teaching has helped me immensely. It ensures I keep my knowledge fresh and it has taught me to adapt to new scenarios. Teaching student nurses makes me excited for the future – especially in the ICU – as we grow and try new things and embrace new technologies. It energizes me to think of the students I will teach and the role I will play in helping them learn and grow into the nurses they are capable of becoming. It’s exciting to think of how they will contribute to the nursing profession and shape what nursing will look like in 20 years. I will always encourage my students to never stop learning and to always strive for better knowledge and patient care. The nursing role is ever evolving and our responsibilities are always increasing. I’m sure my future as a nurse will develop and with the aspirations I hold close to me, I look forward to fulfilling my potential. We have to respect the difficulties and uncertainties we sometimes face, but I believe this is a time to be excited about being a H nurse. I know I am. ■ Chris Burden is a Registered Nurse at Markham Stouffville Hospital and a Critical Care Instructor at George Brown College.
Workplace violence Continued from page 19
The Supreme Court of Canada has acknowledged that while the duty to act in the best interests of a corporation includes a duty to treat all stakeholders equitably and fairly, situations may arise where it is impossible to accommodate all stakeholders (see BCE Inc. v 1976 DebentureholdH ers, 2008 SCC 69). ■ Michael Watts is a Partner in the Toronto office of law firm Osler, Hoskin & Harcourt LLP, and is Chair of the firm’s Health Industry Group. David Solomon is an Associate in the Toronto office of law firm Osler, Hoskin & Harcourt LLP and is a member of the firm’s Health Industry Group. www.hospitalnews.com
EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
New nurse-led ICU team improves patient safety By Jane Kitchen
jax resident and heart patient Philip Herdsman appreciates the teamwork at Rouge Valley. In fact, it may have saved his life. The support of the new Critical Care Outreach Team (CCOT) means the 64-year-old didn’t need to be placed in the intensive care unit (ICU). Herdsman was admitted to Rouge Valley Ajax and Pickering (RVAP) hospital campus with symptoms of pneumonia and he wasn’t getting better on antibiotics that had already been prescribed elsewhere. He was diagnosed with a systemic infection. During rounds, his physician noticed signs of sepsis (a system-wide infection that can cause organ failure) and asked the nurse-led CCOT to follow the patient. Along with close monitoring of his vitals, the team has educated Herdsman and his wife, Yvonne, on the particular challenges of his case, including making sure his lungs stay clear and avoiding infection in his new heart valve. The team addressed the couple’s concerns, giving them the information they needed to be collaborative participants in his healthcare. Says a grateful Yvonne Herdsman: “This team means extra help for the patients. It takes the concern off the patient and the family.” The Critical Care Outreach Team is committed to improving the safety of admitted patients through early recognition of deteriorating situations, to potentially save lives, optimizing patient care and outcomes. Funded by the Ministry of Health and Long-Term Care, Critical Care Services Ontario (CCSO) is continuing to build critical care rapid response teams throughout the province to achieve these goals. At RVAP, if any one of the care team members identifies early warning signs, they will be able to call for the CCOT to see the patient and provide expert clinical assistance. Katherine Stokes and Fran O’Connell, registered nurses in the ICU, co-lead the team of 10 nurses. All of the CCOT nurses are experienced and trained in critical care. CCOT offers education, clinical care to patients, and support to their colleagues and families. All of this improves patient safety and the patient experience during their hospital stay. “With this team, patients receive critical care expertise at an early stage, which can keep them out of the ICU altogether, or get them admitted into the ICU faster,” says
(Above) Patient Philip Herdsman prepares to blow into an incentive spirometer so CCOT nurses Fran O’Connell, left, and Lisa Parker can assess his lung function. Stokes. “Ideally, the patient gets admitted into the ICU before the patient’s condition deteriorates to a point that a code blue would be called. Quicker intervention means the patient spends fewer days in the ICU,” adds O’Connell. CCOT also helps critically ill patients transition from the intensive care unit to the inpatient wards, streamlining the adjustments for patients and their families during the post-ICU stay. Since the initial trial period began in June, 57 patients have been assessed by the CCOT, with nine admissions to the intensive care unit. Hospital staff and physicians in all of the adult inpatient wards, the emergency department and post-anaesthesia care unit are on board with the new process and consult with the new team. On September 1 the CCOT nurses start offering 24/7 support on a 12-hour rotation. They can provide care if the most responsible physician is not available. The team then activates their approved advanced medical directives. Dr. Ari Bay is the medical director of critical care at Rouge Valley Health System and is the CCOT physician lead. “The physicians on our team are very supportive of CCOT. They are our eyes on these patients when we can’t be there,” he says. “It provides great continuity of care that a CCOT nurse is always available.” CCOT continues to educate clinical staff (including nurses and allied health) on when and how to call them for help, using tools such as roadshows and ABCD laminated-cards on calling criteria that staff could wear on their lanyards. (See sidebar.) “CCOT supports the floor nurses,” says Stokes. “When they notice a patient’s changing and deteriorating vital signs, such as increased heart rate or decreased blood pressure, they call the team, and we follow-through with advanced care the patient needs using a collaborative approach involving the patients’ care team.” Says Evangeline Andaya, manager of critical care: “This collaborative approach used by CCOT supports our
culture of safety throughout the hospital.” CCOT has improved patient care by allowing more patients to stay on their units, avoiding the need to move to the ICU or return to it. It is also especially beneficial
for patients to stay where they and their H families know the nursing team. ■ Jane Kitchen is communications specialist at Rouge Valley Health System.
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SEPTEMBER 2015 HOSPITAL NEWS
EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
Are Ontario hospitals ready?
Preparing for the next ( SARS, natural disaster, riot, etc.) By Richard Bochenek and Dr. Brian Schwartz
re Ontario hospitals prepared for the next pandemic? Do we have the right systems and processes in place to deal with the next public health emergency? How do we handle the seasonal flu versus emerging infectious disease outbreaks? These are questions asked every day by people who work in public health. What led us here? Let’s look back. On Feb. 23, 2003, an elderly woman returned to Toronto from visiting family in Hong Kong. Shortly thereafter, she developed pneumonia and died at home in the care of her son. On March 7, the son presented to the emergency department of a Toronto hospital, setting off a chain of events leading to the largest outbreak of Severe Acute Respiratory Syndrome (SARS) outside of Asia. By August, there were 375 probable and suspect cases (there was no confirmatory laboratory test available for this novel infectious agent then); half were health care workers, and three of those workers succumbed. Why was Ontario so ill-prepared for a novel communicable disease? The reasons were many, including not enough public health capabilities and resources, poor hospital infection control, and a lack of health system emergency preparedness. In the aftermath of SARS, and as a result of post-SARS commission reports, infection prevention and control in hospitals was enhanced, public health capacity in Ontario was expanded, and the Public Health Agency of Canada and Public Health Ontario were created. But structures alone do not make hospitals better prepared. Many hospitals and health organizations embarked on emergency preparedness and response training, incorporating such concepts as incident management systems, hazard identification risk assessment processes, and staff training and exercises. How have we fared? If responses to the 2009 H1N1 pandemic, the 2013 Alberta floods and Ontario ice storm, and preparedness for such large events as the G8/
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G20 and Pan/Parapan American Games are any indication, pretty well. Where can we do better? Consider seasonal flu that seems to challenge public health, primary care, acute care and longterm care almost every winter. We have learned to prepare well for the last disaster but we do not have the level of situational awareness and basic emergency preparedness skills embedded in our systems to be able to respond nimbly to smallerscale events. As with infection prevention and control, a basic level of daily preparedness and risk assessment is the key to mitigating low-level threats such as a norovirus outbreak, and responding to higher-level threats such as the emergence of infectious agents like Ebola virus disease. Ebola virus disease was unique, both in its level of destruction in West Africa and in the levels of precaution taken in first-world countries. Suffice it to say that a health system with good basic public health, emergency preparedness and infection control systems would be relatively well-protected against an Ebola epidemic. However, that may not be as true in non-communicable disease emergencies. When Hurricane Sandy was approaching New York City in 2012, staff at some of the hospitals had been warned that it would be like Hurricane Irene from 2011. Intended to convey a sense of urgency, it actually had the opposite effect as many of these hospitals had weathered Irene just fine. In fact, Hurricane Sandy pushed ahead a storm surge that was double the height of Irene. Millions of gallons of wa-
We have learned to prepare well for the last disaster but we do not have the level of situational awareness and basic emergency preparedness skills embedded in our systems to be able to respond nimbly to smaller-scale events. ter pounded into one hospital’s basement levels, destroying everything in its path including its emergency power system and several diagnostic imaging suites, totalling hundreds of millions of dollars. This was not an unexpected terror attack; it was a forecasted weather system that was reported in real-time by 24/7 news media. How could these world-class facilities be so heavily impacted? It comes down to the emergency management program. Emergency planning and response must be rooted in an ‘all-hazards’ approach that identifies the emergency roles and responsibilities of key staff. It must include a robust incident management system identifying who is ‘in charge’ based on the needs of the event. The program must be sufficiently scalable and flexible to deal with incidents from a spill in the laboratory to
a pandemic. It needs to ensure the right people are in the command centre to deal with events as they occur, because most incidents don’t match the assumptions of the scenarios in our limited and pre-scripted library of hospital codes. Looking at the Canadian context in hospital emergency preparedness, the rate of losses to flooding has been rising steadily for decades. Consider the Peterborough floods of 1998, 2004 and 2012, and the Toronto and Calgary floods of 2013. How well prepared are we for such events today? The physical location of hospital critical infrastructure should be assessed; auxiliary power generators and their associated electrical transfer switches, as well as emergency operations centres, are sometimes located in the sub-basements of hospitals. This is done to keep vital systems in low-traffic areas that don’t impact patient-care areas but they are vulnerable to flood damage, and risk assessments should identify this. We have made progress since SARS but we still have a long way to go. Continued education in emergency preparedness and response for all hospital staff, appropriate to level of involvement, and recognition of the scalability and flexibility of incident management models will allow us to normalize response to both small and H large incidents. ■ Richard Bochenek is the Emergency Management Operations Coordinator, Public Health Ontario and Dr. Brian Schwartz, is Chief, Communicable Diseases, Emergency Preparedness and Response, Public Health Ontario. www.hospitalnews.com
EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
Implementing an infection prevention and control program
By Tina Dunlop
utbreaks of infectious diseases, over the past decade, call attention to the urgency of existing and emerging threats to worker health and safety. While the presence of biological hazards can occur in all workplaces, literature suggests that health care settings are among the most vulnerable. In Ontario, more than 800,000 people work in the health care sector at more than 6,000 hospitals, long-term care homes, retirement homes, and community care worksites. According to the Workplace Safety and Insurance Board (WSIB), an average of 1000 workers are infected and become ill due to occupational exposure each year. Employers need to be familiar with organisms that can affect the workplace and plan how to minimize their spread. As such, infection prevention and control (IPAC) is an integral component of a workplace’s occupational health and safety program. Progressive workplaces recognize that developing and implementing a successful IPAC program necessitates commitment and participation of all individuals throughout the organization, including occupational health and safety specialists and their Joint Health and Safety Committees or Health and Safety representatives. They also understand that even though program components may vary according to specific business environments and activities, three fundamental priorities need to remain consistent: risk reduction, legislative compliance and continual improvement.
According to the Workplace Safety and Insurance Board (WSIB), an average of 1000 workers are infected and become ill due to occupational exposure each year. Organizations and associations like the Public Services Health & Safety Association and Public Health Ontario have developed self-assessment tools and best practice resources to help prevent the transmission of infections from clients to workers, and limit the introduction of infections by care providers to other workers and clients. With the aid of such tools, an action plan and implementation strategy can be put in place. The following steps are recommended to proactively manage biological hazards in the workplace: • Identify all actual and potential exposure to infection control hazards • Assess the level of associated risk and set priority for action • Review and revise existing measures and procedures to eliminate and / or control identified risks • Communicate organizational expectations and provide relevant infection prevention and control training • Evaluate the program at least annually, more frequently as required by emerging infectious disease risks and as new resources become available A multidisciplinary approach is recommended for completing any risk assessment. Appropriate departments, managers, www.hospitalnews.com
staff, the joint health and safety committee and infection control specialists should be involved in the process. Engaging management and labour as health and safety partners also strengthens the capacity to address factors, such as people, equipment, materials, environment, and work processes, which contribute to biological work exposures. Active participation in health and safety ensures that workers know their rights, understand the law, and are aware of how to minimize risk in the work environment. A comprehensive infection control program should include, but is not limited to, the following key components:
• Pre-placement assessment of new workers • Health care worker immunization • Screening and surveillance measures • Risk management framework • Hand hygiene program • Routine practices and additional transmission-based precautions • Outbreak control strategy • Relevant IPAC policies and procedures • Training and education • Post-exposure management, reporting and documentation An organizations’ occupational IPAC program should be guided and supported by the following items:
• Management commitment to occupational health and safety • Legislative accountability and shared responsibilities • Precautionary approach to protect workers from the transmission of infection • Resources to support the infection prevention and control program pursuant to the type of workplace and identified risks • Designated person(s) responsible for coordination and oversight of the program • Routine monitoring in accordance with the Regulation 67/93 for Health Care and Residential Facilities Continued on page 24
YOUR ADVANTAGE, in and out of the courtroom.
SEPTEMBER 2015 HOSPITAL NEWS
EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
Real-time wait clock manages expectations in emergency department By Alannah Smith
e live in a world where information is always accessible and at our fingertips. You can find the answer to nearly any question, anywhere, at any time – and this mobile world has conditioned us to expect nothing less. So how do you accommodate this growing need to know answers immediately in a setting that wasn’t built around this need?
The real-time wait clock is a patient-centered communication tool designed to enable realtime information on the current wait times in the emergency department. Following the expansion of Markham Stouffville Hospital (MSH), the emergency department (ED) was facing a challenging time meeting the expectations of patients in this increasingly mobile world. Patients felt they weren’t being kept in the loop on wait times; registration and triage staff were being pulled away from their duties to answer questions about who would be seen next – all while the number of emergency visits continued to grow. The number one question patients ask in the ED is how long will I wait? To help satisfy patients’ needs for constant progress updates without interrupting the flow of the ED, MSH searched for an answer that provided patients with the information
they were looking for without the need for extra manpower. The solution – a real-time wait clock in the ED and online. The real-time wait clock is a patientcentered communication tool designed to enable real-time information on the current wait times in the ED. Designed and formulated with input from the very patients who visit and make use of ED services, the wait clock delivers a simple, visual message that indicates the estimated wait time to see a physician as well as the projected wait time over the following six hours based on past trends. In early 2015, MSH introduced the first wait clock in the ED at the Markham site, followed by the launch of the online wait clock and Uxbridge site wait clock. Now, anyone sitting in the ED at either site, or anyone with a computer or mobile device can access, in real-time, information about the current state of the Markham and Uxbridge site EDs. “Staff and patients have really enjoyed having ready access to the information and have found the wait clock to be a very useful tool,” says Clint Atendido, Director, Emergency, Surgical Services and Patient Flow. “The numbers also speak for themselves – we have had over 15,000 visits to the wait clock online alone since the online launch on April 1, 2015.” From the minute you realize you need to visit the ED, life is on hold for patients and their families. For some people, that means figuring out what to do with children, figuring out work schedules and planning for rides to and from the ED. Having access to the wait clock not only
Cari McCulloch, ED RN uses online wait clock in Markham Stouville Hospital’s emergency department. helps patients and families within the ED – it helps them prior to their visit. Patients and their families can access the Markham and Uxbridge site clocks online and make plans to accommodate their visit with accurate information, making their time less stressful and more about direct patient care. The online clock also lists other care providers/alternatives to the ED in the area to help patients make an informed decision about whether the ED, a walk in clinic or a phone call to Telehealth Ontario is the best option for them. “The wait clock is visual and easy to understand. It keeps patients informed and frees up staff to provide direct patient care,” says Cari McCulloch, ED RN. “Our ED puts a high importance on good patient/provider communication and this clock is another tool we can use to keep patients informed – and most importantly, it ensures staff, patients and visitors all
Patients benefit from blood clot technology By Heather Brown
ime is of the essence for a patient suffering from massive blood loss. For the health care team to treat his or her injuries, every effort must be made to control or stop the bleeding first. St. Michael’s blood lab is using an innovative test known as the rotational thromboelastometry or ROTEM® to help clinicians determine the most appropriate clotting product, whether it be plasma, platelets or medications such as tranexamic acid. St. Michael’s is the first hospital in Canada to use this test in a clinical environment. Other facilities are using it in research settings and are looking to St. Michael’s for insight into how best to implement it clinically. “ROTEM® has changed the way we care for patients suffering from massive bleeding,” says Dr. Sandro Rizoli, trauma director at St. Michael’s and one of two physicians who championed implementing this test at the hospital. “We no longer have to wait for multiple tests to be run or guess which clotting products may work.” HOSPITAL NEWS SEPTEMBER 2015
Photo by: Yuri Markarov, Medical Media Centre.
Mary Choi, a lab technologist, prepares a blood sample to be run through the ROTEM® test. This technology enables the trauma team to watch a clot form in real-time on a monitor in the trauma room via a computer in the lab. As soon as the team sees how the clot is forming and how strong it is, a member from the team calls the
have access to the same information at the same time.” The wait clock displays wait times in 30 minute increments and updates every five minutes with high accuracy; 90 per cent of patients are seen within the projected time. The Markham and Uxbridge site wait clocks are one more step in improving and enhancing the patient experience at MSH. An informed patient is an empowered patient – and the best outcomes happen when patients are partners in their care. Together with Oculys, the wait clock technology provider, MSH is changing the patient experience – one click at a time. MSH’s real-time ED wait clocks can be H accessed online at www.msh.on.ca ■ Alannah Smith is a Corporate Communications Specialist at Markham Stouffville Hospital.
hospital’s blood bank and orders the specific clotting product needed to stop the bleeding. This typically happens within 10 minutes. Previously the trauma team would receive a standard delivery of six units of red blood cells and four units of plasma, followed by four units of red blood cells and four units of plasma, every 20 minutes. This was done for every patient suffering from massive blood loss regardless of size, gender or whether he or she actually needed plasma or red blood cells. “While it is still too early to tell how much blood has been saved since introducing ROTEM®, we are hoping to see a more appropriate usage of blood components that are ordered to treat a patient suffering from massive bleeding and fewer components being wasted,” says Dr. Katerina Pavenski, medical director of the Transfusion Medicine Laboratory at St. H Michael’s. ■
Continued from page 24 • Recognition of safety excellence and opportunity for continual improvement It is imperative that all reasonable precautions are taken to prevent transmission of infectious diseases to protect the health and safety of all health care workers. Look for reliable and credible resources to assist you in the development and enhancement of your infection prevention and control program. At the same time ensure you are addressing legislated requirements under the Ontario Occupational Health and Safety Act and implement best practices as recommended by Public Health Ontario, the Public Health Agency of Canada, Canadian Standards Association, Ontario Medical Association, and Ontario Hospital Association. Building a culture of health and safety by including education and training supports the principle of shared responsibility and personal commitment at all levels of your organization for H health and safety. ■
Heather Brown is a Senior Communications Adviser at St. Michael’s Hospital.
Tina Dunlop, RN, BScN, MScN is Regional Consultant, Public Services Health & Safety Association. www.hospitalnews.com
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EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
First brain surgery of its kind in Canada By Ania Basiukiewicz
urrent technological advances in brain microsurgery have resulted in patient outcomes that would have been impossible just a few short years ago. Patients are now recovering much faster, and have significantly higher success rates. Trillium Health Partners’ Mississauga Hospital has a busy regional neurosurgery program, with at least 500 people benefitting from therapeutic interventions on the brain and spinal cord last year. Most recently, during a one-of-a kind, minimally invasive procedure, Trillium Health Partners’ ventricular brain surgeon, Dr. Mihaly Kis, deftly removed a live parasitic cyst from a patient’s brain. Ever since Doris Gomez Rueda moved to Toronto in 2009 from her native Colombia, things were not quite right. She began experiencing intense headaches, and took over-the-counter pain medication for relief. Doris’ health took a drastic turn for the worse on February 28th, 2015, when she went to bed with flu-like symptoms and was found unresponsive by her daughter early the next morning. After suffering several seizures, and receiving care at two Toronto hospitals, Doris was transferred to Trillium Health Partners’ Mississauga Hospital, which is equipped to manage complex neurological cases. Trillium Health Partners’ Infectious Diseases and Tropical Medicine Specialist, Dr. Sumontra Chakrabarti, used several MRI images to confirm the presence of tapeworm cysts in Doris’ body. Tapeworm infections, or neurocysticercosis, are common in developing countries such as Colombia, where lower sanitation standards can often lead to people ingesting microscopic tapeworm eggs present in contaminated water. Tapeworm cyst infestations can take several years to mature in a person’s body. Growing cysts can put pressure
Trillium Health Partners’ Dr. Sumon Chakrabarti with Doris Gomez Rueda. on the brain, sometimes causing seizures. While tapeworm infections in the human bowel are quite common and treatable with anti-parasitic drugs, Mrs. Rueda’s case was unique: the infection spread beyond her body and even brain tissues, and the tapeworm larvae travelled all the way to the ventricular system within her brain. She required immediate surgery to save her life. Ventricles are cavities within the brain where spinal fluid is made and circulates. Spinal fluid supports the brain and provides lubrication between surrounding bones, the brain and spinal cord. “I’ve seen tapeworm larvae in brain tissue many times before, though this is the first time I’ve seen it in the ventricle, outside of a textbook,” explains Dr. Sumontra Chakrabarti. “A blockage in these small tunnels of the
Tapeworm cyst infestations can take several years to mature in a person’s body. Growing cysts can put pressure on the brain, sometimes causing seizures. brain is like a blockage in an artery. It can be fatal.” Dr. Mihaly Kis performed Doris’ lifesaving procedure, using microsurgery to get through to the infected ventricle, deep at the centre of the brain, without having to perform risky invasive brain surgery. Trillium Health Partners’ neurosurgery program specializes in safer, micro-neu-
rosurgical procedures like this one, utilizing state-of-the-art technology. For Doris’ surgery, Dr. Kis used a special navigational device that matched the patient’s MRI imaging with her actual head position and anatomy, tracking the instrument in the surgeon’s hand. “The conventional surgical approach would have been to cut through the patient’s brain in order to reach the ventricle at the centre of the head,” says Dr. Kis. “Using the navigation tool instead, we were able to minimize our incision and work within 1mm accuracy. The entire surgery was done under a microscope connected to a navigational device, effectively providing a GPS roadmap during the surgery and allowing the roadmap to be projected, creating a holographic like view, much like fighter pilots use during air combat.” Using a combination of delicate microsurgical instruments, Dr. Kis was able to remove two tapeworm cysts, gently extracting the entire cysts without rupturing them. Doris has recovered well from her surgery, and is taking strong antibiotics to remove the rest of the infection. “Throughout this entire process, Trillium Health Partners staff have become like family to me and my son and daughter,” says Doris, most of whose family still lives in her native Colombia. “I am forever grateful for the kind of care I received here, which would not have been possible to get at home. The doctors and nurses are our angels in Canada.” Trillium Health Partners is the only regional centre specializing in neurosurgery between Toronto and Hamilton, resourced with state-of-the art equipment and medical expertise to ensure patients in the region have faster access to life-saving H treatments. ■ Ania Basiukiewicz is a Communications Advisor at Trillium Health Partners.
New urgent care centre opens in Vaughan By Stefanie Kreibe
very day, Mackenzie Health’s Emergency Department cares for 250 or more patients with a variety of illnesses serving over 93,000 patients annually. Mackenzie Health serves one of Canada’s fastest growing communities with over a half million people now residing in Southwest York Region. To help meet the steadily increasing needs of its growing community, this June, Mackenzie Health introduced a new Urgent Care Centre (UCC) at 9401 Jane St. in Vaughan, for patients of all ages that require care for urgent but nonlife threatening conditions or illnesses. Susan Kwolek, Executive Vice President and Chief Operating Officer at Mackenzie Health, says an urgent care centre is a great alternative for those people with less serious illnesses or injuries. The team at the UCC provides on-site diagnosis and treatment services and the facility is barrier-free and accessible for all. “We know that the community of Vaughan is growing in leaps and bounds HOSPITAL NEWS SEPTEMBER 2015
Jessica Mitchell has a cast set by Dr. David Rauchwerger, Chief of Emergency Medicine at Mackenzie Health at the new Urgent Care Centre in Vaughan, Ontario. and is in need of reliable, accessible healthcare closer to home. As we work to develop and build the future Mackenzie Vaughan Hospital, this is an important first step in bringing these services to this growing community,” she says. Staffed by experienced physicians and nurses who also work in the hospital’s
Emergency Department the Urgent Care Centre can diagnose and treat a wide variety of illnesses and injuries as well as provide x-rays, stitches, lab results and cast broken bones. The UCC currently cares for an average of 32 patients daily with the ability to increase capacity when needed. Approxi-
mately 30 per cent of the patients being cared for are children. These non-urgent patients are able to be seen more quickly at the UCC then they could in the Emergency Department which is really better equipped to care for more serious injuries and illnesses. “For some conditions and injuries, a trip to the Emergency Department cannot and should not be avoided, such as stroke, chest pain or major trauma,” adds Chief of Emergency Medicine at Mackenzie Health, Dr. David Rauchwerger. “Those patients should go directly to their nearest Emergency Department for care. For people needing care for most bumps, burns, breaks or illnesses an Urgent Care Centre could be the right choice to be seen quickly and efficiently.” Open 365 days a year, the UCC is staffed by Mackenzie Health’s Emergency Department physicians, and nurses. On weekdays, it is open from 4:00 to 10:00 p.m. and weekends and all holidays it is H open from 10:00 a.m. to 4:00 p.m. ■ Stefanie Kreibe is a Communications and Public Affairs Consultant at Mackenzie Health. www.hospitalnews.com
Evidence Matters 27
Neuropathy: What a pain By Dr. Janice Mann
o one wishes to experience pain. Fortunately when those everyday aches and pains arise, we have over-the-counter medications readily available to help us out. (For a recent review on what the evidence has to say about over-the-counter pain medications, check out the Ask Julie column at Vox with Canada’s own Julia Belluz: http://www.vox.com/2015/8/17/9165189/ best-painkiller-tylenol-aspirin-advil). But what if you are experiencing pain that isn’t likely to get better with these over-the-counter medications? Patients with neuropathic pain find themselves in this category. Neuropathic pain – or as it is sometimes called, neuropathy – is a type of chronic pain that results from damage to the nervous system. Neuropathic pain can be peripheral, resulting from damage to the peripheral nerves (nerves in your arms, legs, hands, and feet for example) or central, resulting from damage to the brain or spinal cord. Common causes of peripheral neuropathy include diabetes and postherpetic neuralgia (nerve pain following shingles). Causes of central neuropathy can include spinal cord injury and multiple sclerosis. Neuropathic pain is notoriously difficult to treat and may involve both pharmacological and physical therapies. Although painkillers – both over-the-counter and prescription – may be tried, they are not always successful in treating the pain, and in the case of opioids can lead to abuse and addiction. Other classes of medication, not typically used for pain, can be helpful in the treatment of neuropathic pain. These include antidepressant medications and medications normally used to prevent seizures, called anticonvulsant drugs. Gabapentin, an anticonvulsant originally developed for the treatment of epilepsy, is sometimes used off label to treat neuropathic pain. It is thought to work by inhibiting the transmission of nerve signals in the brain. While gabapentin has been viewed by some health care professionals as a promising option for the treatment of neuropathic pain, others are concerned about the potential for abuse (at high doses it may be associated with sedative and dissociative or psychedelic effects). Because of the uncertainty of the role of gabapentin in the treatment of neuropathic pain, decision-makers in the Canadian health care system turned to the Rapid Response service at CADTH – an independent, evidence-based agency that finds, www.hospitalnews.com
assesses, and summarizes the research on drugs, medical devices, and procedures – to find out what the evidence says. When CADTH searched for the evidence on gabapentin and neuropathic pain, they found 19 relevant publications – nine systematic reviews, two randomized controlled trials, six non-randomized studies, and two guidelines. Overall, the evidence suggests that gabapentin is effective in the treatment of neuropathic pain. A greater reduction in neuropathic pain was found with gabapentin compared with placebo (no active drug) in adults who have a variety of conditions, including diabetic peripheral neuropathy and postherpetic pain. For short-term treatment of painful diabetic neuropathy and postherpetic neuralgia, gabapentin may be as effective as two classes of antidepressants known as tricyclic antidepressants and serotonin norepinephrine reuptake inhibitors, and another drug for seizures called pregabalin – but these findings are based on indirect evidence (evidence on each drug individually rather than evidence that directly compares the drugs with one another). The evidence for gabapentin for other types of neuropathic pain is limited.
Neuropathic pain – or as it is sometimes called, neuropathy – is a type of chronic pain that results from damage to the nervous system.
The number of adverse events was higher in patients taking gabapentin compared with patients taking placebo (side effects reported include somnolence, dizziness, peripheral edema, and gait disturbances); but, overall, serious adverse events were few and comparable between the two groups. Gabapentin may be used as a recreational drug, but there is an absence of high-quality evidence on the prevalence and risk of misuse among patients prescribed the drug to manage neuropathic pain. No Canadian evidence-based clinical practice guidelines were identified, but UK
guidelines support the use of gabapentin as one of the first-line treatment options for the management of neuropathic pain. US guidelines recommend gabapentin as an option for diabetic neuropathy. Knowing the evidence on gabapentin for the treatment of neuropathic pain can help to guide decisions about its use – as well as identify areas where more research is needed. As more evidence on gabapentin and neuropathic pain becomes available, further reviews may be necessary to ensure policy and clinical practice is in keeping with the latest evidence. If you’d like more information about the CADTH Rapid Response service,
please visit www.cadth.ca/RapidResponse. If you’d like to see what other drugs, devices, or procedures have been covered by the Rapid Response service at CADTH, visit www.cadth.ca/RapidResponseReports. Here you’ll find all of the freely available reports listed chronologically as they are completed. To learn more about CADTH, visit www.cadth.ca , follow us on Twitter: @CADTH_ACMTS, or talk to our Liaison Officer in your region: https://www.cadth.ca/contact-us/liaisonH officers. ■ Dr. Janice Mann is a Knowledge Mobilization Officer at CADTH.
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SEPTEMBER 2015 HOSPITAL NEWS
28 Nursing Pulse
Nurses say health and healthcare
matter most in the 2015 federal election By Marion Zych
ntario’s nurses have called on all candidates running in the federal election to remember that health and healthcare matter to Canadians. The Registered Nurses’ Association of Ontario (RNAO) released its policy platform in August, outlining its recommendations that will put health front-and-centre leading up to voting day on Oct. 19. Why health matters highlights the crucial areas that affect an individual’s ability to be healthy and outlines policies and programs to create healthier communities. RNAO’s platform also addresses key issues to improve the health system. “Nurses are an integral part of our health system and our practice gives us a unique window into the broad range of factors that foster ‘healthy’ people and communities,” says RNAO President Vanessa Burkoski, adding that “…access to affordable housing, measures to reduce poverty, and a clean environment are just as important as dealing with security matters, but have received little attention so far.” The association’s platform contains 17 recommendations that cover five areas: medicare, access to care, social determinants of the health, the environment, and fiscal capacity, says Burkoski, emphasizing that “…these will help members of the public choose the right candidate.”
HOSPITAL NEWS SEPTEMBER 2015
Canada’s health care system urgently needs the engagement of all political parties and a prime minister committed to working with the provinces and territories to strengthen medicare to include home care and a national pharmacare program. “Canada’s health care system urgently needs the engagement of all political parties and a prime minister committed to working with the provinces and territories to strengthen medicare to include home care and a national pharmacare program,” says Doris Grinspun, RNAO’s chief executive officer. “Registered nurses (RN), nurse practitioners (NP) and nursing students are deeply committed to the principal of health for all, and will pressure the next government to fully restore the Interim Federal Health Program, which provides refugee claimants with access to primary care.” RNAO notes health care was barely mentioned during the first all-party leaders’ debate on Aug. 6, and the association says it must receive more serious attention as the campaign unfolds. “This election campaign is long enough for members of the public to look at the health issues that affect Canadians day-in
and day-out. The federal government has as a central role to play in ensuring peoplee are healthy and that the system meetss their care needs, regardless of whetherr they live in a small rural town in New w Brunswick, a large urban city in Ontario,, or an isolated First Nations communityy in northern Manitoba,” says Grinspun. The platform is one of many ways nurses are speaking out during the election campaign. A series of all-candidates meetings will take place in federal ridings throughout Ontario with nurses leading spirited debates among MP hopefuls. RNAO is also releasing a questionnaire to all party leaders; and a comparison of the various party platforms ahead of voting day. For a copy of the association’s federal election platform, or to find out more about getting involved and additional resources available to voters, visit RNAO. H ca/election2015 ■
Marion Zych is director of communications for the Registered Nurses’ Association of Ontario (RNAO), which this year celebrates its 90th anniversary. RNAO is the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario.
EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
Critical care response team enhances patient safety By Steven Gallagher
hen Tim Dunn was admitted to Niagara Health System’s St. Catharines Site for knee surgery in July, he figured he would be discharged a few days after his procedure. But the unexpected happened. Following his surgery and his admission to the Inpatient Surgical Orthopedic Unit, Mr. Dunn started having trouble breathing. A nurse on the unit realized there was a need to activate the NHS’s new Critical Care Response Team to assist Mr. Dunn. The Critical Care Response Team (CCRT) is a group consisting of a dedicated critical care nurse, respiratory therapist and Intensive Care Unit (ICU) physician available 24 hours-a-day, seven days a week to bring their critical care expertise to the patient’s bedside, or wherever it is needed, with the aim of caring for patients who are seriously ill outside of a hospital’s ICU. Within minutes of the call, the CCRT had arrived at Mr. Dunn’s room and began providing care. “It was comforting to know the response team came as quickly as they did,” says Mr. Dunn’s wife, Mary Ann. “They explained to me what they were doing. They wanted to stabilize his heart.” After being stabilized, Mr. Dunn spent a night in the ICU and then returned to his surgical unit to continue his recovery from knee surgery. Mr. Dunn had high praise for the CCRT. “It’s too perfect,” says the retired high school teacher. “It’s what you would expect of a health care system. It was very professional.” In February 2015, the provincial government and Hamilton Niagara Haldimand Brant Local Health Integration Network announced they will provide Niagara Health System $1 million annually to support a Critical Care Response Team to improve patient safety.
There are 25 Registered Nurses, 25 Respiratory Therapists and 10 intensivists on Niagara Health System’s Critical Care Response Team. Early identification of patients in need allows the response team to either stabilize them on the ward or facilitate their early admission to the ICU. In addition to enhancing patient safety, including improved outcomes, CCRTs have been shown to increase staff engagement and satisfaction across the organization. Nancy Ulch, who is a Charge Nurse on the Inpatient Surgical Orthopedic Unit at the St. Catharines Site, says the front-line health care team welcomes the addition of the CCRT. “It’s a huge weight off their shoulders because the unit staff know there is someone they can contact immediately,” says Ms. Ulch. “There is a comfort in knowing www.hospitalnews.com
Tim Dunn with his wife, Mary Ann, in his room at the St. Catharines Site of the Niagara Health System. Photo credit: Anna Cobian the patients being cared for by the Critical Care Response Team are being well taken care of. There is always open communication with the response team. If they need something, we are there to help them or they are there to help us. The communication is great. It’s that awareness that in a situation, the nurses can get help. It’s almost like a lifeline.” The CCRT launched its pilot phase – running eight hours a day Monday to Friday – on June 15 and plans to begin 24/7 service in mid-September Behind the successful launch of the CCRT has been its implementation task force made up of a multi-disciplinary team of nurses, respiratory therapists, physicians, pharmacists, educators and administrators. Key in the creation of the CCRT was using a team approach to training, says Dr. Christian. “The team that is going to work together needs to train together,” explains Dr. Christian, who before joining the NHS in January 2015 was the Medical Director of the Critical Care Response Team at Mount Sinai Hospital in Toronto. “In this case, we brought the doctors, nurses and respiratory therapists that are going to be working together into one room. They all went through the exact same training, which relied heavily on simulated situations. We need that practice beforehand so we can do it well when it counts.” Dr. Christian says the training focused less on medical skills – “these people already have these skills” – and more on team skills. “The team skills are important. It’s the communication, how they work together,” he says. “How they operate in a different environment outside the ICU.” Also crucial in the training was working with team members on how to communicate with patients’ family members who may be present during CCRT calls. In addition to caring for a patient, the team can be used to identify opportunities for improvement in the system, Dr. Christian adds. As well, the team monitors all patients
who are transferred from the Intensive Care Unit to another medical or surgical unit for 48 hours after the move to aid in the transition out of the ICU. Dr. Christian leads the Critical Care Response team with Elayn Young, Niagara Health System’s Clinical Manager of Critical Care and Respiratory Therapy. Ms. Young describes the CCRT as a “significant patient safety initiative
that is representative of best practice.” “The team provides another safety net for our patients,” says Ms. Young. “The creation of the Critical Care Response Team is another example of our commitment to patient safety. It’s one more added H layer of protection.” ■ Steven Gallagher is a Communications Specialist with the Niagara Health System.
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EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
Fighting antimicrobial resistance By Sandra Morrison
ince the first widespread use of penicillin in the 1940s, antibiotics have saved countless lives, including thousands of World War II soldiers who would have died, not in combat, but from their infected wounds. Before antibiotics, 90 percent of children with bacterial meningitis died, and infections such as tuberculosis and pneumonia largely resulted in serious illness or possibly death. But even when accepting his Nobel Prize in 1945, Alexander Fleming, considered the father of antibiotics, was prophetic about their potential misuse. Although his words at the time raised concerns more about potential under dosing – exposing microbes to non-lethal quantities of the drug making them resistant – excessive or inappropriate use over the decades has led to the spread of antibiotic-resistant infections in hospitals. Canada experienced its first case of methicillin-resistant Staphylococcus aureus (MRSA), just one type of bacteria responsible for nosocomial infections, in 1981, and by 1995 a dramatic increase in MRSA had been reported across the country. Each year more than 220,000 health care associated infections result in between 8,500 to 12,000 deaths in Canada.
Antimicrobial stewardship An essential weapon hospitals can use in the battle against antibiotic resistance is implementing a robust Antimicrobial Stewardship Program (ASP). Stewardship is defined as overseeing and protecting something worth caring for and preserving. Antimicrobial stewardship means using antibiotics only when necessary, and selecting the appropriate antibiotic at the correct dose, route, and duration. An antimicrobial stewardship program optimizes the use of antimicrobials to achieve the best patient outcomes and reduces the risk of infections, the spread and development of antimicrobial resistance, the incidence of health care-acquired infections and health care costs. ASPs should not be considered the purview of only large-scale hospitals. Instead an ASP could be a menu of interventions – adaptable and customizable concepts that can be designed to fit the infrastructure of any hospital, no matter what the size. A comprehensive, evidence-based antimicrobial stewardship program may include a number of interventions based on local antimicrobial use and available resources, such as: • Prospective audit and feedback • Formulary of targeted antimicrobials and approved indications • Education • Guidelines and clinical pathways • Antimicrobial order forms • Streamlining or de-escalation of therapy • Dose optimization • Parenteral to oral conversion Organizations are encouraged to tailor an approach to antimicrobial stewardship consistent with their size, service environment, and patient population, and HOSPITAL NEWS SEPTEMBER 2015
Canada experienced its first case of methicillin-resistant Staphylococcus aureus (MRSA), just one type of bacteria responsible for nosocomial infections, in 1981, and by 1995 a dramatic increase in MRSA had been reported across the country. to establish processes for ongoing monitoring and improvement of the program over time. Despite this, community hospitals are often challenged by a lack of resources dedicated to antimicrobial stewardship and limited access to infectious disease specialists. Nonetheless, ASPs can be successfully implemented even in these situations. Working together is key to a program’s success. An ASP requires an inter-disciplinary approach, with collaboration between the antimicrobial stewardship team, pharmacy, and hospital infection control. The involvement and support of hospital administrators, medical staff leadership, and health care providers is essential. Components of a program are interventions to optimize antimicrobial use, and mechanisms to evaluate it on an ongoing basis and share results with stakeholders.
Required organizational practice Accreditation Canada’s Required Organizational Practice (ROP) on ASP was first evaluated at on-site surveys in 2013. (ROPs are evidence-informed practices that mitigate risk and contribute to improving the quality and safety of health services.) The ROP calls for organizations to implement an antimicrobial stewardship program that meets specific tests for compliance. In this first year of assessment, the ROP received the lowest national compliance rate at 57 per cent. The ROP is designed for organizations to establish an ASP approach tailored to their size, service environment, and patient population. Successful implementation requires an inter-disciplinary approach across multiple teams, and low compliance may indicate that many organizations’ programs are still in develop
ment. On an encouraging note, the 2014 accreditation results show a small increase in the compliance rate to 63 per cent.
Education and research In an effort to help organizations meet the challenges of implementing an ASP, Accreditation Canada has created an online course with the Mount Sinai Hospital and University Health Network Antimicrobial Stewardship Program. Using case studies, tools, resources, and interactive exercises, participants consider their hospital’s unique context, challenges, culture, and resources to tailor and customize an antimicrobial stewardship program for their organization. Ongoing research is also important. Along with a number of leading health care organizations, Accreditation Canada is contributing to a Canadian Institutes of Health Research funded project aimed at building capacity to improve and sustain antimicrobial stewardship programs in ICUs. Working with stakeholders across the country to implement ASPs is but one way Accreditation Canada is meeting its vision of Excellence in quality health serH vices for all. ■ Sandra Morrison is a Writer/Editor at Accreditation Canada.
Award-winning program keeps patients and staff safe at Mount Sinai Hospital By Riannon John
reventative medicine’ is taking on a new meaning at Mount Sinai Hospital where a proactive approach to keeping both patients and staff safe has just been recognized with a national award. The 2015 National Healthcare Safety Award from the Canadian College of Health Leaders celebrated the success of Mount Sinai’s Safe Patients/Safe Staff Program, which provides resources to help staff safely and effectively care for patients who are at risk of aggressive or dangerous behavior while in hospital.
The challenge of risky patient behaviour Hospital stays can be very distressing and disorienting for some patients, particularly elderly patients who suffer from dementia or other mental health issues. Certain health conditions can also cause delirium in patients with no history of mental illness. The result can be impulsive or defensive behaviour that can put patients at risk by compromising their care, and increasing the likelihood of staff experiencing harm and burn-out as they care for these patients. The issue is of growing importance. As our population ages, acute care organizations are increasingly called upon to serve these high-risk patients admitted for medical and surgical care.
Jocelyn Bennett and Dr. Lesley Wiesenfeld accepting the award from members of the Canadian College of Health Leaders.
Collaborating to find solutions Mount Sinai’s Nursing and Psychiatry teams are working together to address these challenges. These departments jointly developed the Safe Patients/ Safe Staff Program, led by Dr. Lesley Wiesenfeld, Head of Geriatric Psychiatry Consultation Liaison Service and Deputy Psychiatrist-in-Chief, and Jocelyn Bennett, Senior Director of Urgent and Critical Care. Initial results show a 20 per cent drop in staff
reporting being targets of incidents of aggressive behaviour. “These strong results show that Safe Patients/Safe Staff is making a difference,” says Bennett. “The program is an important part of our commitment to creating an organizational culture of safety that supports staff and provides the best care to our patients. It is an innovative approach that balances staff and patient safety, to the benefit of everyone involved.” Continued on page 32 www.hospitalnews.com
From the CEO's Desk 31
Health services integration in a small Ontario community
By Varouj Eskedjian
n January 2013, I took on the role of President and CEO at Haliburton Highlands Health Services (HHHS). While the transition into the CEO role has had its expected growing pains, the adjustment to the position has been more challenging by virtue of its location in a small rural community in the Province and because of integration initiatives that have resulted in the restructuring of the organization. Lessons learned through the past several years of transformation will assist in HHHS’ achievement of the vision to become Leaders in Innovative Rural Health Care and enable the organization to develop as a rural health hub. Living and working within a hospital/ health care organization in a small community has tremendous benefits, as well as some burdens. Small and rural communities cherish their health service providers, support them financially and through volunteering efforts, and appreciate their importance from both a health and economic perspective. In Haliburton County, HHHS is the second-largest employer and one of the community’s most cherished institutions. The per capita level of support to the HHHS Foundation and two Auxiliaries are higher than that of larger communities in Ontario. As CEO, I am mindful of the relative importance of health services in the community and constantly need to take this into consideration in leading HHHS, managing organizational issues and in contemplating any organizational changes. As well, I have become fully aware of the dynamics of living and working in a small community which affords minimal anonymity and confidentiality of what goes on in the organization. Upon my arrival in Haliburton County, HHHS was thrown into a Central East LHIN-directed community health services integration planning exercise with other community health agencies in the County and larger health care providers in the adjacent City of Kawartha Lakes. The Final Integration Plan called for the transfer of community services from the smaller agencies to HHHS to become the sole LHINfunded health services organization in the County. This recommendation reflected the strongly held position that local governance and management of health services was paramount to governors of HHHS and the other County-based community health agencies. The outcome of the Haliburton County/ City of Kawartha Lakes integration planning process was the development of HHHS as a more fully integrated health services delivery organization providing the majority of the continuum of healthcare for the community. On October 1, 2014, following the integration and transfer of community services, HHHS launched a Community Support Services Division that includes: supportive housing, adult day programs, foot care coordination, a community hospice program and a wide array of community support services, including meals-on-wheels, social recreation and congregate dining, transportation services, friendly visiting and security www.hospitalnews.com
Small and rural communities cherish their health service providers, support them financially and through volunteering efforts, and appreciate their importance from both a health and economic perspective. checks, Home First and Home at Last, and falls prevention. Because of HHHS integration achievements, in January 2015 the Central East LHIN also approved an investment of more than $1.1 million for a specialized comprehensive geriatric community team, a palliative care community team and assisted living services for highrisk seniors. The community services division now complements the Hospital Division that includes two emergency departments in Minden and Haliburton and a small acute care unit at the Haliburton site, the Long-Term Care Division that includes two long-term care homes operating 92 beds in total (62 beds at Hyland Crest in Minden and 30 beds at Highland Wood in Haliburton), and the community mental health program based out of Minden. The restructuring of HHHS as a result of the “vertical” integration with community providers was only part of recent organizational changes. The other significant effort over the past three years has been the development of a joint venture/ preferred partner relationship with Ross Memorial Hospital (RMH) in the City of Kawartha Lakes. While there was significant local opposition throughout the in-
Varouj Eskedjian tegration planning process for a potential merger of HHHS and Ross Memorial, the Board of Directors of HHHS was fully supportive of the strategic alliance with RMH. The “horizontal” integration between the two hospital organizations has resulted in a number of joint leadership positions, harmonization of telephone systems and shared information technology (IT), joint leadership training, and fee-for-service arrangements for the provision of central processing/sterilization services, laboratory services, pharmacy services and procurement services. The quality, service, expertise and efficiency gains for HHHS through the joint venture have been endorsed by the Board because they have not come at the price of the organization’s independence. However, the closer relation-
ship with Ross Memorial Hospital has had a mixed reception from HHHS staff and physicians. There are a number of lessons learned from the Haliburton County integration experience over the past several years that can be applied to other small and rural communities in the Province contemplating restructuring into rural health hubs through integrations with community partners. In the HHHS experience, while there has been an appreciation of the quality and access gains for the organization and the community resulting from organizational integration and the joint venture with RMH, these changes have caused anxiety among staff who perceive potential job losses as a result of all the restructuring. Not surprisingly, this anxiety has also spilled over into the community, raised concern about the impact on services and become larger issues to be managed. In hindsight, a sound change management strategy, including ongoing communication with the Board, management, staff, physicians, volunteers and the community could have potentially minimized concerns and garnered greater buy-in from internal and external stakeholders. The integration experiences at HHHS, including for me as CEO, are important because as Ontario’s health services landscape changes, further organizational transformation is anticipated. Similarly, as many small and rural hospitals/health care organizations look to become health hubs to meet current and future service pressures, HHHS can be a model to emulate given similarities to other communities H across Ontario. ■ Varouj Eskedjian is President & CEO, Haliburton Highlands Health Services.
SEPTEMBER 2015 HOSPITAL NEWS
EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
Mount Sinai safety Continued from page 30
Safe Patients/Safe Staff
Photo credit: Tom Gebicz
Ornge Advanced Care Flight Paramedic Stephanie Delaire and Primary Care Flight Paramedic Mathieu Coulombe.
Managing pain when preparing patients for air transport By Jo-Anne Oake-Vecchiato
reparing a patient for transport involves a targeted assessment of needs, and for those who have experienced an ambulance transfer, they know pain and/or comfort is a key consideration. There may be multiple transitions to and from hospital beds, ambulance stretchers, land vehicles and/or aircraft. The transport environment is unpredictable and challenging with weather implications, noise, a vibrating aircraft and confined space. Patients may be transferred to a facility with a specialized service, higher level of care or repatriated to their community hospital. Regardless, effective pain management and comfort measures will optimize a transport experience. Ornge surveys patients to understand their perceptions of the transport experience. In 2013-14, patients noted 90 per cent satisfaction, stating that the team definitely did all they could for comfort, and 76 per cent noted that the transport team did all that they could to control pain. Nineteen percent (19%) stated pain was controlled for the most part and HOSPITAL NEWS SEPTEMBER 2015
four per cent noted pain was somewhat controlled). Patients cited pain in all ranges: mild, moderate or severe.
As a result of patient feedback, evidence-based guidelines for clinical management of acute and chronic pain were reviewed and used to develop a quality improvement pain initiative at Ornge. Key to meeting patient needs is collaboration with all health care partners, in order that patient requirements can be anticipated and patients can be prepared for an air medical environment. Hospital staff and physicians are instrumental in preparing patients; knowing the patient provides a unique opportunity to provide comfort measures and/or analgesia based upon previous assessments and evaluations of response. Pain management and comfort are an important aspect of the care provided to patients. Through collaborative efforts with our health care partners, Hospital staff/physicians and the Ornge transport team can make a significant difference in the transport experience H for patients. ■
This checklist is an example of some of the things health care providers can do to optimize a patient’s transport.
Jo-Anne Oake-Vecchiato BScN, MHSc is Director, Corporate Quality and Patient Safety at ORNGE.
The program has four key components that deliver on improved outcomes for patients and staff. 1. Proactive and responsive clinical care including a Behavioural Rapid Response Team, electronic surveillance to identify at risk patients, proactive geriatric psychiatry consultation for high-risk patients, and family engagement. This approach features a special team of nurses called BOOST (Behavioural Optimization and Outcome Support Team), who immediately perform an assessment and engage any specialists required. Led by clinical nurse specialists Carla Loftus and Mavis Afriyie-Boateng, BOOST is always on-call. Together with the original care team, they determine a strategy for managing the risk and a care plan that will meet the patient’s needs. 2. Standardized best practices and process re-engineering implemented through a toolkit including evidence-based care plans, order sets, and a behavioural discharge summary. This toolkit gives all caregivers the resources they need to take the best approach to caring for the particular needs of these patients, developed by experts. 3. Organization-wide collaboration that has integrated the program across the organization through executive sponsorship and partnerships with key departments including Occupational Health, Wellness and Safety, Human Rights and Health Equity, Organizational Development. 4. Multimodal training focused on building the capacity of staff through e-learning, interactive workshops, simulation, debriefing and system wide dissemination of the program. This training is continued through ongoing coaching and support in real-life situations that reinforces best practices. “We developed our Safe Patients/Safe Staff Program to improve the hospital experience for our most vulnerable patients, their families and the dedicated clinicians who provide frontline care,” says Dr. Wiesenfeld. “As we refine and evaluate our efforts, we continue to strive for responsive, person-centred care and a culture of compassion towards our patients and our staff.”
Sharing and adapting the program The program’s success has garnered interest from other hospitals and health-care organizations. “This award speaks to the national leadership of the Safe Patients/Safe Staff Program,” says Dr. Molyn Leszcz, Psychiatrist-in-Chief at Mount Sinai Hospital. “We are very proud of the team for creating an innovative solution to this growing challenge. This is an important part of our efforts to treat the whole patient, offering an integrated approach to care for both the body and the mind by bringing together our medical and psychiatric expertise.” Safe Patients/Safe Staff is the type of innovative program that may be adapted for different care environments as Mount Sinai Hospital joins forces with Bridgepoint Active Healthcare and Circle of Care as part of the new Sinai Health System. Established in January 2015, Sinai Health System aims to create a premier exemplar of an integrated health system for H the future. ■ Riannon John is Senior Specialist, Media Relations at Mount Sinai Hospital. www.hospitalnews.com
EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
New technologies have ‘raised the bar’ in rapid diagnostics which helps influence more appropriate antibiotic therapy that is better for patients and for our health care system.
An agar plate being smudged with a concentrated pellet of a positive blood culture.
Rapid diagnostics to support treatment Sunnybrook’s Microbiology lab innovates to make the most of newer diagnostic technologies. By Natalie Chung-Sayers
f Louis Pasteur were to walk into a typical hospital microbiology laboratory today, he would feel very much at home. Since the 1880s when he discovered the principles of vaccination, fermentation and pasteurization, methods tried and true, such as growing cultures in petri dishes, are still the mainstay of how microbiologists and technologists identify and characterize infectioncausing organisms. However, given his curiosity-seeking mind, Pasteur would also likely be intrigued by newer innovative molecularbased diagnostic technologies that have been developed and introduced in laboratories in the last five to 10 years. These technologies are used in tandem with traditional methods for faster diagnosis, for example, of bloodstream infections and antibiotic resistant organisms such as MRSA (methicillin resistant Staphylococcus aureus) and C. diff. (Clostridium difficile). “New technologies have ‘raised the bar’ in rapid diagnostics which helps influence more appropriate antibiotic therapy that is better for patients and for our health care system,” says Dr. Andrew Simor, Chief, Microbiology and Infectious Diseases, Sunnybrook Health Sciences Centre. Sunnybrook’s lab is one of only a small number in Ontario with expertise in PCR (polymerase chain reaction) technologies. It is also one in only about a third of hospital laboratories across the country with expertise in newer MALDI-TOF MS (matrix assisted laser desorption ionization-time of flight mass spectrometry) technology.
A concentrated pellet smudge plate yields within 4 hours, sufficient bacterial growth for MALDI-TOF MS analysis and specific identification of this Gram-negative organism. www.hospitalnews.com
Making the most of these technologies to expedite diagnosis and support treatment, Sunnybrook’s lab team has improved upon conventional specimen preparation methods for MALDI-TOF MS and for PCR analysis: • Use of the MALDI-TOF MS in the lab in combination with judicious use of antibiotics has been associated with lower 30-day mortality in patients with bloodstream infections. Dr. Simor and a team of microbiologists and lab technologists demonstrated the effectiveness of a modified smudge plate method for more rapid and accurate identification of organisms causing bloodstream infection. The identification was done from positive blood cultures or cultures shown to have an organism present in the blood. The method uses a novel concentrated pellet that yields within four hours, sufficient bacterial growth for MALDI-TOF MS analysis and identification. This method involves preparation of an agar plate smudged with the concentrate of the blood culture, before it is incubated at a controlled temperature to be grown or cultured. With this simple technique, the cause of bloodstream infections can be identified 24 to 48 hours earlier than with conventional laboratory procedures, and this has a direct beneficial impact on patient care and outcome. Results of their study were recently published in The Journal of Clinical Microbiology. Of 400 plates prepared in this way, for MALDI-TOF MS analysis, 97 per cent of Gram-negative bacilli and 85 per cent of Gram-positive organisms were correctly identified within four hours. Similar to previous studies of MALDITOF MS analysis of samples from positive blood cultures, best results were obtained with Gram-negative organisms, for examples, E. coli, Klebseilla, and Pseudomonas aeruginosa. • When the World Health Organization declared an H1N1 (influenza A) pandemic due to a new strain of the virus in 2009, Sunnybrook’s microbiology lab, like other hospital labs, had to respond quickly to increase the ability to detect the virus. The team increased diagnostic capacity by testing influenza A and B in a duplex format using PCR technology to detect both viruses simultaneously. PCR technology is used in the lab to amplify or make more copies of a speci-
men or particular piece of DNA (genetic information) of a virus or bacteria. A method called Thermal Cycling exposes the specimen to consistent heating and cooling which supports a chain reaction in the specimen that amplifies its DNA. Microbiologists and technologists can then identify the type of pathogen based on DNA band images. This duplex PCR analysis for influenza virus detection improved sensitivity and yielded results in a significantly shorter time – within hours instead of days – than with the conventional approach of direct immunofluorescence assessment
and the culture method. Faster results supported expedited treatment and helped inform specific infection control measures if needed. “The more that we can innovate to expedite diagnosis and do so accurately and in an optimal way for laboratory workflow, the stronger the impact to influence selection of appropriate antimicrobial therapy and the greater the benefit of improved outcomes for patients,” says H Dr. Simor. ■ Natalie Chung-Sayers is a Communications Advisor at Sunnybrook Health Sciences Centre.
Leading Science. Leading Practice.
OCTOBER 25 28, 2015 Sheraton Centre Toronto Hotel
www.criticalcarecanada.com SEPTEMBER 2015 HOSPITAL NEWS
EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS
Life-changing procedure for people with
chronic heart conditions By Jane Kitchen
he Central East Regional Cardiac Care Centre, based at Rouge Valley Centenary hospital campus in Scarborough, is offering a new chronic total occlusion (CTO) angioplasty procedure. Patients with CTO have chronic blockages in their hearts that they could have been living with for months or even years. They might be suffering from chest pain or shortness of breath during physical activities despite medications prescribed by their cardiologist. Robert Keene, 63, of Oshawa, was one of those patients. He could tell something was wrong. He felt different, uncomfortable, and was slowing down. “I had shortness of breath, a dull ache when exerting myself, and a very low energy level,” he says. “I thought I had indigestion, and it was very bad in the evenings,” he adds. Keene did not know that he had a CTO – in his case, a complete blockage in his heart’s right artery. Dr. Chris Li is an interventional cardiologist with the regional cardiac care program. “Someone with a CTO can have a 100 per cent blockage in his or her heart but not have a heart attack,” he explains. “Unlike a heart attack caused by a sudden complete blockage of a major coronary blood vessel, these blockages develop slowly. When this happens over time, sometimes the heart does its own bypass and builds up collateral arteries to get blood flow around the blockage. However, these vessels aren’t big enough to keep an adequate supply of oxygen to the heart during exercise causing some patients’ lifestyles to be very limited by these symptoms.”
With a highly qualified and experienced team of more than 20 cardiologists and 100 health care professionals, the Central East Regional Cardiac Care Program is integrated with the community to ensure excellent, timely care. This inadequate supply of oxygen was causing Keene’s symptoms. His initial tests indicated the need for a percutaneous coronary intervention (PCI) – an angioplasty procedure that clears blockages in blood vessels in the heart, often using a stent. However, even after two PCIs, the artery still could not be unblocked. Fortunately, the new CTO service was available at Rouge Valley’s regional cardiac care centre. The life-changing procedure was performed on him by Dr. Li and RVHS cardiologist Dr. Ram Vijayaraghavan the following week. “Dr. Li and Dr. Vijay were wonderful,” says Keene. “They talked to me the whole way through the procedure as I watched on the screen. They answered any questions I had right away. And, they were successful in removing the blockage,” he says. HOSPITAL NEWS SEPTEMBER 2015
Dr. Ram Vijayaraghavan (right) and Dr. Chris Li perform a chronic total occlusion (CTO) angioplasty procedure. As home to the Central East Regional Cardiac Care Centre serving Scarborough and Durham region, Rouge Valley’s Centenary hospital campus is depended upon for its PCI service that treats 1,500 patients a year. Starting in February 2014, the regional cardiac centre began offering the new CTO angioplasty procedure so that even more patients can be treated. Now Rouge Valley is one of a few centres in Ontario
with a dedicated CTO program for regularly performing this extremely specialized procedure. “With a normal angioplasty, we take a soft metal wire and feed it through a soft clot or blockage in an artery,” explains Dr. Vijayaraghavan. “Then, we would use this wire like a monorail and run a balloon and stent equipment along it so that we can clear the blockage. With a CTO, the artery
has been 100 per cent blocked for a long time, so we cannot use traditional angioplasty wire methods to clear it. In some cases, a creative approach of passing the angioplasty wire through the collateral vessels to the ‘back door’ of the blockage, called a ‘retrograde approach,’ is used. It is like opening a blocked tunnel from both ends. Continued on page 39
Using information to transform the emergency department landscape By Kaeli Stein and Kevin Feng
ntario emergency departments are committed to enhancing the patient experience with strategies to improve wait times and access to care. The amount of time patients spend in the emergency department (ED), known as length of stay (LOS), has been steadily decreasing over the past seven years. As of May 2015, overall provincial ED LOS has decreased by 18 per cent compared to the 2008 baseline. This performance improvement has occurred despite steadily increasing patient volumes. Notably, volumes have been at record highs for the past six months, with an all-time record of ED visits set this past May at 487,167. Timely province-wide information gives us a clear picture of gaps or issues which enables hospitals to implement strategies and allocate the necessary resources to address them. We are now seeing the benefit of these efforts: improved access to emergency care for our patients. With continuous support from the Ministry of Health and Long-Term Care, Access to Care (ATC) at CCO has enabled the health system to evolve through information management, analytics, and public reporting. Through extensive collaboration with health system partners, ATC continues to enable performance improvement through the use of information
provided in the Quarterly ER LHIN Summary Reports. The Quarterly ER LHIN Summary Reports were inspired by the successful release of the Provincial Summary Report last year. In May 2015, ATC released 14 LHIN-specific reports distributed via email to over 250 LHIN and hospital stakeholders.
As of May 2015, Ontario’s emergency department length of stay has decreased by 18 per cent compared to the 2008 baseline. The LHIN reports narrate the story of three key patient categories within the region: admitted patients, non-admitted patients and overall patients. The report gives a voice to the patient experience throughout the health system, which is illustrated through key performance indicators. The reports also guides hospital and LHIN executives through the analytics, providing context using trends, highlights and correlations which they can use to make and track improvements.
“In an age of ‘big data’, the LHIN reports are the first in the ATC-ER series to be developed in direct collaboration with hospital and LHIN users, creating a unique report that contains only relevant, digestible information,” says Jason Garay, Vice President, Analytics and Informatics, CCO. The reports offer a standardized approach for all LHINs to monitor the progress of current initiatives by assessing impact on ED wait times, identifying top performers, best practices, and local issues, and supporting decision-making on future initiatives. A consistent view of regional performance including meaningful metrics, hospital peer groupings, and reporting aggregates is critical to effective provincial discussions and driving systemic improvement. Hospital staff can subscribe to receive this report via email or download it from the ATC website. One direct benefit of these reports is the ability for hospitals to use data to align their staffing needs with the peak hours where patient volumes are the greatest, ultimately resulting in reduced wait times For more information on Access to Care initiatives, please email CCO at H ATC@cancercare.on.ca. ■ Kaeli Stein is Manager, Clinical Effectiveness and Kevin Feng is a Senior Business Analyst at CCO. www.hospitalnews.com
Health Care Technology 35
Baycrest innovation will help with transitions in care
By Kelly Connelly
aycrest Health Sciences has developed a solution to improve transitions in care for persons with dementia-related responsive behaviours. Responsive behaviour is a health care term used to describe behaviours that are in response to a trigger such as the environment, care or pain. When an individual with dementia-related responsive behaviours is returned to their original nursing home after a short-term stay in a behavioural assessment or psychiatric unit, a thick file of discharge papers goes with them outlining the new care plan. It’s at this point that a carefully customized care plan can go off the rails. The nuanced ways or special steps for delivering care to an individual with high intensity behaviours do not always translate well in a written document. Not surprisingly, after a period of time the individual can end up back on a behavioural or psychiatric unit. To address this transition conundrum, Baycrest has created a cloud-based, video library to enrich the written plan with real-life video capture. The aim is to help point-of-care staff quickly learn the most effective ways to engage and communicate with a particular client that reduces the risk of challenging behaviours. Care staff would simply access the video clips on a
password-protected in-h ternet site and brush up on the sequence off steps for any particular episode of care, whether it is bathing or deescalating an anxious or aggressive behaviour. The video clips convey what most written care plans age, tone of voice, can’t – the body language, eye contact, and even choice of words that staff need to use when communicating with that person. Aptly named Care in Transitions, the innovative tool generated strong interest when it was introduced by Gary Gallagher at a health conference last year. “We are ahead of the curve with this prototype,” says Gallagher, clinical manager on the behavioural unit in Baycrest’s hospital and project lead. “This tool not only builds capacity for nursing home staff to better manage challenging behaviours in certain residents, but has the potential to reduce medication use, recidivism of behaviours, and emergency transfers.” Clients with high intensity behaviours often strain point-of-care resources in hospitals and nursing homes. It can take a
Carolyn Wong, occupational therapist, holds a small camera. small army of three to four care providers, for instance, to bathe one client with challenging behaviours. When a nursing home or hospital can no longer manage a client who is aggressive, anxious and resistant to care, the individual is transferred to a hospital psychiatric ward or a specialized behavioural unit such as the one Gallagher works on. Such individuals can also be transferred to the Transitional Behavioural Support Unit at Baycrest’s long term care facility for a short-term comprehensive assessment. The goal of a specialized unit is to understand the whole person – who they were (including their role or profession in life), their cultural and spiritual back-
Photo credit: Kelly Connelly.
ground, favorite hobbies, likes and dislikes – and identify the antecedents to their responsive behaviours. Triggers can include underlying pain, boredom or lack of stimulation, and even the way staff interacts with the person. A new care plan is carefully designed to provide the most effective behavioural intervention program. In addition to medication (which is often still necessary), strategies can include engaging the client in meaningful activities during the day that are touchstones from their past, using simulated presence (soothing voice recordings of a family member), and music therapy. Continued on page 39
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Paediatric programs and developments in the treatment of paediatric disorders. Specialized programs offered on an outpatient basis. Developments in the treatment of neurodegenerative disorders, traumatic brain injury. Social work programs helping patients and families | | AUGUST 2015 VOLUME 28 ISSUE 9 www.hospitalnews.com address the impact of illness.
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36 Health Care Technology
Bladder home monitoring By Cheryl Niamath
pinal cord injury (SCI) is a devastating, life-changing event. Depending on the severity of the injury and the area of the spinal cord that is damaged, the most outwardly-obvious effect of SCI is full or partial paralysis. However, people with SCI also experience a myriad of secondary complications including autonomic dysreflexia, pressure ulcers, cardiovascular dysfunction, pain, spasticity, and–frequently–urinary tract infections. Urinary tract infections are the most prevalent, and potentially preventable, secondary complication of SCI. Because loss of sensation is common among people living with SCI, the diagnosis of UTI is not always straightforward and often requires the involvement of specialized health care professionals and equipment. One non-invasive method to check bladder health is an optical technique known as NIRS (near-infrared spectroscopy). Developed in the late 1970’s by UBC researcher Dr. Andrew Macnab, NIRS uses light to detect changes in blood flow and oxygenation in the bladder as it contracts to pass urine. These changes differ depending on whether a patient has a healthy or diseased bladder. Drs. Lynn Stothers, Mark Nigro and Babak Shagdan, researchers at Vancouver’s ICORD spinal cord injury research centre, developed a way for bladder function to be monitored using a small selfcontained wireless NIRS system that is taped to the skin over the bladder. For the past two years, wireless bladder monitoring has been done at Vancouver General Hospital’s spine outpatient clinic. However, for many people living with SCI, getting to the clinic can present a considerable challenge, especially for those who live outside the city. Even people living near to health care facilities still face geographical, meteorological and transportation barriers.
Urinary tract infections are the most prevalent, and potentially preventable, secondary complication of spinal cord injury. To address this issue, Drs. Lynn Stothers, Nigro and Shagdan have recently started testing a bladder home monitoring system for people with SCI. The home monitoring system allows patients to do their own data collection (the same way people can take their own temperature or blood pressure), using a small home NIRS system that is able to transmit data to the investigators using a cell phone and laptop. The Rick Hansen Institute is now funding a study to investigate whether regular monitoring of bladder health linked to home video-conferencing between participants and a research nurse is beneficial to people with SCI-related bladder problems. The researchers believe that making it possible for people to check their own bladder health at home is empowering, increases independence, and will provide HOSPITAL NEWS SEPTEMBER 2015
The research team. Pictured L-R are Dr Babak Shadgan, Dr. Mark Nigro, Ms Teresa Lee, and Dr. Andrew Macnab. better quality of life. It also saves time and money for both patients and the health care system, and will be important for people with SCI – with a NIRS monitor patients can check their bladder health every day if they want, without any risk or inconvenience, making it possible for a patient to have early warning of a possible urinary tract infection without having to make an appointment with a health care
specialist until the possibility of an infection has been detected. In the past, urinary tract infection leading to sepsis or renal failure was the leading cause of death in people with SCI. While this dubious distinction now belongs to heart disease, urinary tract infection is still a serious condition that affects the health status, community participation and general quality of life of people with SCI, and
is estimated to cost over $60 million per year in Canada. With an estimated 85,556 people currently living with SCI in Canada and approximately 4,259 new cases per year, it seems clear that finding new ways to detect or mitigate the severity of urinary tract infections in people with SCI will improve the lives of people with SCI and save limited health care dollars. ICORD is a world leading health research centre focused on spinal cord injury. From the lab-based cellular level of understanding injury to rehabilitation and recovery, our researchers are dedicated to the development and translation of more effective strategies to promote prevention, functional recovery, and improved quality of life after spinal cord injury. Located at Vancouver General Hospital in the Blusson Spinal Cord Centre, ICORD is supported by the University of BC Faculties of Medicine and Science, and Vancouver Coastal Health Research Institute. Visit www.icord.org. For more information about the bladder home-monitoring study at ICORD, see: icord.org/studies/2014/10/home-basedobservations-and-monitoring-of-eventsrelated-to-urinary-tract-infections-in-sciH home-sci/ ■ Cheryl Niamath is a Communications and Administrative Manager, ICORD.
Automated monitoring of staff hand hygiene compliance By Didier Bouton
he Canadian Patient Safety Institute reports that about 220,000 people – or one out of every nine patients admitted to the hospital each year in Canada – acquire infections while being treated for something else. About 8,000 – 12,000 patients die as a result of these infections. The number one way to reduce the spread of infections in a hospital is by health care workers complying with guidelines for cleaning their hands. However, health care staff only clean their hands as frequently as they should 39 per cent of the time, and only 8.5 per cent of the time are all steps in the proper hand washing technique followed. Such improper handwashing practices can result in the spreading of germs from patient to patient and, ultimately, in health care acquired infections (HAIs). While any preventable death or complication is too many, this is particularly poignant when it comes to paediatric patients. The Hospital for Sick Children (SickKids) in Toronto is the first hospital to install the DebMed Group Monitoring System (GMS) in Canada, and the first paediatric hospital to do so in North America. GMS automates measurement of hand hygiene compliance and provides unbiased, accurate data in real time. This system has been proven to increase hand hygiene compliance while facilitating the culture of safety for both patients and staff.
A multifaceted hand hygiene approach Based on a scientifically validated algorithm, the GMS tracks how many times staff members clean their hands against how many times they should have cleaned their hands based on hospital-specific data. A research study published in the American Journal of Infection Control, demonstrated that over a yearlong study, the DebMed GMS system reported the same hand hygiene compliance rates as those reported by 24/7 video monitoring. “SickKids is committed to being a leader in quality through continuous improvement and optimizing patient safety,” says Richard Wray, Director of Quality, Safety, Infection Control at SickKids. “Experts agree that a multifaceted, multidisciplinary hand hygiene program must be implemented in all health care settings. Measurement, feedback and staff engagement are among the core elements of a multifaceted approach. The data from the DebMed GMS hand hygiene monitoring system will be a useful tool to help improve hand hygiene compliance and help reduce infection rates.”
Choosing a higher clinical standard In addition to using the scientifically proven hand hygiene compliance measurement method, the system tracks compliance based on the “Four Moments
for Hand Hygiene”, a higher clinical standard than the practice of cleaning hands upon the entrance and exit of the patient room. Recommended by the Ontario Ministry of Health and Long-Term Care, the methodology outlines each time health care professionals should wash their hands. The Four Moments are: 1. Before patient/patient environment contact 2. Before an aseptic procedure 3. After body fluid exposure risk 4. After patient/patient environment contact Because health care practitioners and patients come into contact constantly, it is necessary for the entire staff to adhere to proper hand hygiene practices to make a difference.
Fostering a culture of teamwork and safety The automated hand hygiene monitoring technology emphasizes improvement of staff hand hygiene performance as a unit, thereby promoting teamwork and compliance at the group level and bringing about a change in hand hygiene behavior. It does not single out individual “offenders” but, instead, allows team members to encourage each other’s hand hygiene practices. Thanks to the timely reporting, the feedback can be nearly immediate. Continued on page 38 www.hospitalnews.com
Health Care Technology 37
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PAV™+ software continuously monitors a patient’s respiratory flow and pressure 200 times per second and changes ventilator support to meet the patient’s demand for each breath, thereby aiding patient-ventilator synchrony.
Mechanical ventilators: Striving for faster patient recovery By Ron Thiessen
ransitioning patients off mechanical ventilation to breathing independently – a process called weaning – is essential before a patient can leave the intensive care unit (ICU). In simple cases, a patient is extubated after the first weaning trial. In difficult and prolonged cases, multiple trials are required. The faster the transition the better; the impact of prolonged mechanical ventilation (PMV) on patients’ health, and the cost of mechanical ventilation to the health care system are considerable. Patients requiring PMV account for up to 10 per cent of all mechanically ventilated patients in ICU, and, due to their extended stays, 40 per cent of ICU bed days and a staggering 50 per cent of ICU costs. The average daily cost for an ICU bed in Canada is $2,908 or more than $1 million a year per ICU bed. These costs are compounded by the fact that the number of patients requiring long-term ventilation continues to grow with the rise in aging population, cardiorespiratory disease and obesity-related conditions. Beyond the costs and discomfort to patients, one of the biggest challenges of PMV is the risk of diaphragm atrophy (when a muscle decreases in size from not being used). Atrophy in respiratory muscles can start within 18 to 69 hours of being placed on a ventilator. In fact, a person being fully supported on a ventilator can lose more than half their respiratory muscle mass in less than a day. It stands to reason therefore that the earlier a patient can start to breathe spontaneously, the sooner the atrophy can be stopped and potentially reversed. Studies have identified a correlation between early weaning and faster recovery for patients, while reducing critical care costs. That’s why we all must come together to champion better patient outcomes for mechanically ventilated patients and reduce the tremendous costs associated with ICU days by getting patients off mechanical ventilators as quickly as possible. Pressure support has been the most commonly used mode to wean difficult and prolonged patients off ventilators. In simple terms, after a patient initiates a breath, pressure support “boosts” air volumes to a www.hospitalnews.com
level specified by the clinician. With pressure support, calculations are somewhat arbitrary in determining when a breath ends, so the volumes provided don’t always encourage patients to make the effort to breathe on their own. This leads to a common phenomenon known as asynchrony, which means the ventilator is not delivering breath in synch with the patient’s needs. Studies have associated asynchrony with longer ICU stays, more ventilator days (as many as 18 extra days on average), and even increases in mortality. Proportional Assist Ventilation (PAV™+) has been developed as an alternative to pressure support. Originally developed by Dr. Magdy Younnes in Winnipeg, and subsequently licensed by Medtronic, PAV™+ software continuously monitors a patient’s respiratory flow and pressure 200 times per second and changes ventilator support to meet the patient’s demand for each breath, thereby aiding patient-ventilator synchrony. User-configurable graphics provide clear visualization of the patient’s work of breathing and other essential information needed to monitor and enhance a PMV patient’s chances for successful weaning. St. Mary’s General Hospital in Kitchener, Ontario has carried out a progressive weaning pilot project, which involved the development of a specialized Weaning Unit and the use of PAV™+ software. In the program’s first year, St. Mary’s General Hospital estimates it saved up to 3,000 ICU days, significantly improving the quality of life for those who were successfully weaned. The cost savings were also significant: an estimated $1.35 million in the first year. St. Mary’s General Hospital’s experience with the PAV™+ showed that use of the software “allows for improved strengthening of the muscles involved in spontaneous breathing and improved patient synchronization with the ventilator during weaning.” As more hospitals adopt PAV™+ software in multidisciplinary care settings, this use is expected to translate into better outcomes for patients, fewer days in ICU, and cost H savings to the healthcare system. ■ Ron Thiessen, a Respiratory Therapist, is an Airway and Ventilation Specialist at Medtronic.
QSeptember 13-15, 2015 Canadian Association of Environmental Management Over the Top for Clean conference and Trade Show Scotia Bank Conference Centre, Niagara Falls Ontario QSeptember 15-16, 2015 National Elder Friendly Hospital Conference Marriott Bloor Yorkville, Toronto Website: www.healthcareconferences.ca QSeptember 17-18, 2015 2015 iHT2 Health IT Summit Rosewood Hotel Georgia, Vancouver Website: www.ihealthtran.com QSeptember 22-24, 2015 Network Leadership Symposium 2015 University of Alberta, Lister Centre, Edmonton, Alberta Website: www.augustana.ualberta.ca QSeptember 26-30, 2015 2015 AHIMA Convention and Exhibit New Orleans, United States Website: www.ahima.org QSeptember 29, 2015 Doing CPOE Right: Patient-Centred Design and Evidence-Based Culture In-Person Live Webcast, Toronto Website: www.oha.com QSeptember 30-October 1, 2015 3rd Annual National Forum on Patient Experience Toronto Airport Marriot Hotel Website: www.patientexperiencesummit.com QOctober 5-6, 2015 Innovations in Laboratory Management for Lab Leaders Conference Marriott Bloor Yorkville Toronto Website: www.exec-edge.com QOctober 25-28, 2015 Critical Care Canada Forum Sheraton Centre Toronto Hotel Website: www.criticalcarecanada.com QOctober 28-29, 2015 2nd Annual Healthcare Practitioners’ Mental Health Conference Marriott Bloor Yorkville, Toronto Website: www.healthcareconferences.ca QNovember 2-4, 2015 Health Achieve 2015 Metro Toronto Convention Centre, Ontario Website: www.healthachieve.com QNovember 16-19, 2015 World Forum for Medicine Duesseldorf, Germany Website: www.medica-tradefair.com QNovember 29- December 4, 2015 RSNA Annual Meeting 2015 McCormick Place, Chicago, United States Website: www.rsna.org QDecember 1–2, 2015 Data Analytics for Healthcare Toronto, Ontario Website: www.healthdatasummit.com
To see even more healthcare industry events, please visit our website www.hospitalnews.com/events SEPTEMBER 2015 HOSPITAL NEWS
38 Health Care Technology
Robots comfort patients at Alberta Children’s Hospital By Janet Mezzarobba
our childlike robots are being used to comfort young patients during stressful medical procedures at Alberta Children’s
Hospital. The two-foot-tall robots, named MEDi (Medicine and Engineering Designing Intelligence), are programmed to mimic the actions of a child and to calm apprehensive patients with small talk and high-fives during procedures, such as vaccinations and blood tests. “Hospitals, even bright and friendly hospitals like this one, can put children on edge, especially if they are here for a procedure that might involve some discomfort,” says Margaret Fullerton, Senior Operating Officer, Alberta Children’s Hospital. “We’ve been testing the MEDi robots here for almost three years and it has become quite clear that this technology significantly improves the health care experience for our young patients and their parents and caregivers. The Alberta Children’s Hospital is fortunate to have access to the first robots in Canada specifically programmed to help children manage painful or stressful medical procedures. It’s a useful – and very cool – technology.” In a recent study conducted by Alberta Health Services and the University of Calgary, 57 children between the ages of four and nine were able to interact with MEDi while receiving their seasonal influenza vaccination at Alberta Children’s Hospital. The study showed children who interacted with the robots reported 50 per cent less pain compared to youngsters who received their vaccination with little or no distraction. “These results show the potential and benefits for using robotics to help manage a child’s pain while having a medical proce-
Alberta Children’s Hospital patient Aidan Sousa interacting with MEDi and Certified Child Life Specialist Cathy Smith. dure done,” says Dr. Tanya Beran, Professor of Community Health Sciences at the Cumming School of Medicine, University of Calgary, who helped program the robots. “Robots can be used during blood tests and IV starts and other uncomfortable procedures, such as stitches or fracture sets. It can even be used for procedures that aren’t painful but cause distress for children, such as X-rays. The opportunities are endless.” Dr. Beran says the robots also give instructions on how to cope and improve the dynamic between child and parent. “Parents know their child is nervous, which makes them nervous. MEDi gives instructions that helps join parent and child together in a common action,” she says. Sheila Sousa says the MEDi robots have been a source of comfort for her nine-
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year-old son, who visits Alberta Children’s Hospital every two weeks for injections to manage his severe asthma. “The procedure wasn’t nearly as uncomfortable with MEDi in the room,” Sousa says. “Not only did it calm him down, but it helped me knowing Aidan was preoccupied and interested in something other than his treatment. It made the entire experience so much easier. All Aidan could talk about after his injection was the robot.” The four robots were funded by community donations to the Alberta Children’s Hospital Foundation for use throughout the hospital, including the Vi Riddell Children’s Pain and Rehabilitation Centre. “We’re so grateful to our generous donors for supporting such innovative technology,” says Saifa Koonar, President and CEO of the Alberta Children’s Hospital Foundation. “Any time pain and distress can be reduced for children, it’s a very good thing.” Developers plan to further enhance the technology by personalizing the interactions through the use of facial recognition software. MEDi would then be able to greet patients by name and customize conversations according to the patient’s history.
The University of Calgary is a leading Canadian university located in the nation’s most enterprising city. The university has a clear strategic direction – “Eyes High” – to become one of Canada’s top five research universities by 2016, grounded in innovative learning and teaching and fully integrated with the community of Calgary. For more information, visit ucalgary.ca. Alberta Children’s Hospital Foundation inspires our community to invest in excellence in child health, research and family centred care. Through the generosity of donors, the foundation provides funding for innovative programs, state of the art equipment, advanced medical training and internationally recognized pediatric research. www.childrenshospital.ab.ca Alberta Health Services is the provincial health authority responsible for planning and delivering health supports and services for more than four million adults and children living in Alberta. Its mission is to provide a patient-focused, quality health care system that is accessible and H sustainable for all Albertans. ■ Janet Mezzarobba is a Senior Communications Advisor at Alberta Health Services.
Hand hygiene compliance Continued from page 36 The result is an increase in the unit’s compliance rate, and the system has been proven to increase compliance by up to 40 per cent. Through the use of the system, infection prevention and control staff can explore a new method of monitoring beyond traditional direct observation, which is still used as a primary form of hand hygiene compliance measurement in many hospitals. Rendered unreliable, in part due to the Hawthorne effect, which results in people behaving differently when they know they are being watched, direct observation can inflate compliance rates by as much as three times the actual rate. Electronic moni-
toring, instead, has earned kudos from more than 60 per cent of professionals, according to a DebMed 2014 survey of more than 130 infection preventionists, nurses and other health care leaders from Canadian hospitals. It is important that today’s hand hygiene champions take advantage of modern, science-based technologies to create and sustain quality and safety iniH tiatives in their facilities. ■ Didier Bouton is President and CEO of DebMed North America. He has more than 20 years of experience working in the area of occupational skincare. www.hospitalnews.com
Health Care Technology 39
Baycrest innovation helps transitions Continued from page 35 â€œWhat you donâ€™t get from a written care plan are the nuances,â€? says Julia Rice, an occupational therapist on the behavioural unit and the projectâ€™s videographer/ editor. â€œThe videos showcase the work our team has done with the client and helps to ensure those relationships and strategies are maintained between the new care team and the client.â€? Video capture covers three key themes: personhood (who the person is), care approach (what the routine looks like), and responsive behaviour (what the behaviour looks like and how the team intervenes). â€œItâ€™s about maintaining a consistent care approach and routine after the client has transitioned,â€? adds Rice.
Responsive behaviour is a health care term used to describe behaviours that are in response to a trigger such as the environment, care or pain. Gallagher describes a video clip of a long term care resident with responsive behaviours who becomes more agreeable with personal care when staff use a â€œsimulated presenceâ€? strategy. As the man lies on his bed, he remains calm and relaxed as he listens to an audio recording of his daughterâ€™s soothing and reassuring voice. Another male client who becomes increasingly agitated at certain times of the day quickly calms down once a nurse places headphones on his head and he hears his favorite singer Frank Sinatra. He relaxes, smiles and becomes more sociable with those around him.
For care providers coming on shift to work with a new client for the first time, they would be able to prep quickly on the most effective care approaches and communication strategies with a particular client with responsive behaviours, by watching the video clips.
Pilot study Baycrest has completed a pilot study on the Care in Transitions cloud-based tool, with encouraging feedback from other long term care facilities who had a chance to use it. Long term care staff noted that, compared to printed words on a discharge summary, the video images and sound communicated a patientâ€™s abilities and challenges â€“ as well as aspects of their â€œpersonhoodâ€? â€“ more quickly and in a more compelling way. This was also confirmed by family members who said they felt less burdened about trying to describe their loved oneâ€™s needs, strengths and abilities to a new group of care providers. Managers and staff said they welcome relevant, timely and accurate information about each clientâ€™s needs and about how care was being managed on Baycrest Hospitalâ€™s Behavioural Neurology Unit. In some cases, nursing homes reported receiving inadequate or missing information about an incoming client from discharging facilities. They also expressed a lack of faith in the relevance and value of some written information accompanying patients during transition. An important theme in the feedback was how video can help reduce unease and fear within the receiving facility when a client with high intensity behaviours is about to be re-admitted (or admitted from home). Discharge destination staff pointed out that viewing the video could save time by speeding up the normal integration (settling in) process. The video clips
Chronic heart conditions
Continued from page 34 Extreme care has to be taken not to damage these very fine vessels,â€? he explains. The new CTO angioplasty procedure builds on the regional cardiac centreâ€™s PCI service, and the regional fast-track emergency cardiac care program that looks to treat Scarborough and Durham patients having a heart attack in the community or at one of the partnering regional hospitals within a 90-minute window. â€œCTO expands the spectrum of care that we offer,â€? says Dr. Li. â€œOur emergency cardiac program saves many lives, beyond a doubt. Now, the CTO service is life-changing for our patients. We can help these sick people who are stable, yet suffering, to improve their quality of life.â€? This was certainly the case with Mr. Keene, who noticed an amazing difference, even right after the procedure. â€œMy energy levels have come back to what was normal for me,â€? he says. â€œI had been slowing down for quite a few months, but now Iâ€™m back to gardening and I walk every day. It has changed my lifestyle dramatically.â€? With a highly qualified and experienced team of more than 20 cardiologists and more than 100 health care professionals, the Central East Regional Cardiac Care Program is integrated with the community to ensure excellent, timely www.hospitalnews.com
care. As the designated cardiac care centre for the regional program, Rouge Valley delivers care in partnership with The Scarborough Hospital, Lakeridge Health, and the Central East Local Health Integration Network (LHIN). Each year, more than 6,500 patients from the Scarborough-Durham area are seen at the cardiac centre for a wide range of cardiac care services, including life-saving emergency and elective interventions to unblock blood vessels in the heart; advanced cardiac imaging to get a better view of whatâ€™s happening with a patientâ€™s heart; and pacemaker and implantable cardioverter defibrillators (ICDs) and electrophysiology procedures to manage and treat arrhythmias (irregular heartbeats). The broader regional cardiac program also offers a communitybased cardiovascular rehabilitation service across the Central East LHIN, working with additional partner hospitals, including Ross Memorial Hospital and Northumberland Hills. To make a cardiologist referral to the Central East Regional Cardiac Care Centre to assess if a patient is a good candidate for the CTO program, please call H 416-284-8131 ext. 5139. â– Jane Kitchen is Communications Specialist at Rouge Valley Health System.
provide visual â€œproofâ€? of the clientâ€™s state, and can be helpful in providing evidence of treatment impact. â€œThe decision to create a secure, password-protected cloud-based website was an easy one,â€? says Gallagher. It provides greater protection of patient health information and confidentiality than a DVD which can easily be lost or misplaced.
Care in Transitions is a multi-disciplinary effort involving Baycrestâ€™s clinicians, nurses, IT specialists, and Innovation, Technology and Design Lab. It recently received an innovation award from H Baycrest. â–
DEADLINE FOR OCTOBER 2015 ISSUE: SEPTEMBER 29, 2015
Kelly Connelly is a Senior Media Officer at Baycrest Health Sciences.
VIEW CAREER ADS AT:
2015 Conference for IEN s
Ramada Plaza Hotel Toronto November 19th â€“ 20th
Internationally Educated Nurses Partners in Healthcare Diversity
visit www.care4nurses.org to book your spot
Looking for more? At VHA Home HealthCare, more is not just our commitment to clients, but to our incredible team of Nurses & PSWs.
Join one of our new Integrated Palliative Care Teams â€” one supporting clients and families in Scarborough and the other in Durham. By providing seamless care focusing on what matters most to our clients and their families, the interdisciplinary teams will enhance the quality of care of palliative clients, with an emphasis on effective symptom and pain management, to improve overall quality of life. ,I \RX DUH ORRNLQJ IRU PRUH LQ D FDUHHU Ĺ? ĹśH[LEOH KRXUV JURZWK RSSRUWXQLWLHV FRPSHWLWLYH EHQHĹľWV FRPSHQVDWLRQ DQG PHDQLQJIXO UHODWLRQVKLSV ZLWK FOLHQWV and families â€” then you belong at VHA! We are currently hiring RNs, RPNs, PSWs and Palliative Care Best Practice Supervisor in the Scarborough and Durham Regions who have a desire to work with palliative care clients and families. Palliative Care Best Practice Supervisor 4XDOLĹľFDWLRQV â€” Undergraduate GHJUHH LQ 1XUVLQJ6FLHQFH LQ 1XUVLQJ DQG FXUUHQW FHUWLĹľFDWH RI FRPSHWHQF\ OLFHQVXUH IURP WKH &ROOHJH RI 1XUVHV RI 2QWDULR SURJUHVVLYH H[SHULHQFH LQ QXUVLQJLQFOXGLQJVXSHUYLVRU\H[SHULHQFHRUDGYDQFHGSUDFWLFHUROHLQHQGRIOLIH care; Valid driverâ€™s license and use of a car on the job required. 51DQG5314XDOLĹľFDWLRQVĹ?&XUUHQWFHUWLĹľFDWHRIFRPSHWHQF\OLFHQVXUH IURP WKH&ROOHJHRI1XUVHVRI2QWDULRFXUUHQW%&/6FHUWLĹľFDWH51 GLSORPD531 Ideal candidates will have â€œFundamentals of Palliative Careâ€? (MoH). In addition WKH\ZLOOKDYH&1$FHUWLĹľFDWLRQLQ+RVSLFH3DOOLDWLYH&DUH1XUVLQJ25DUHDFWLYHO\ pursuing Enhanced Fundamentals and the Comprehensive Palliative Education Program (CAPCE). 36: 4XDOLĹľFDWLRQV Ĺ? 3HUVRQDO 6XSSRUW :RUNHU &HUWLĹľFDWH )LUVW $LG&35 &HUWLĹľFDWHLQ)XQGDPHQWDOVRI+RVSLFH3DOOLDWLYH&DUH02+ 51V 531V DQG 3:6V 5HTXLUHG Ĺ? ([SHULHQFH ZRUNLQJ LQ FRPPXQLW\ VHWWLQJ ZLWK SDOOLDWLYH FDUH FOLHQWV 0XVW EH ĹśH[LEOH WR ZRUN ZHHNGD\V DQG ZHHNHQGV Valid driverâ€™s license and access to a car (for those working in the Durham area) to travel between clients. VHA Home HealthCare is an Equal Opportunity Employer. VHA is committed to creating an inclusive and diverse work environment. If you require an accommodation, let us know in advance. Accredited with Exemplary Status by Accreditation Canada An RNAO Best Practice Spotlight Organization designate and; A founding member agency of United Way Toronto
Interested applicants may apply online at www.vha.ca SEPTEMBER 2015 HOSPITAL NEWS
EMERGENCY SERVICES/CRITICAL CARE/TRAUMA/EMERGENCY PREPAREDNESS BIOMED PRESENTS...
FOOD ADDICTION, OBESITY, & DIABETES A Seminar for Health Professionals TUITION $109.00 (CANADIAN)
Laura Pawlak, Ph.D., M.S.
The seminar registration period is from 7:45 AM to 8:15 AM. The seminar will begin at 8:30 AM. A lunch (on own) break will take place from 11:30 AM to 12:20 PM. The course will adjourn at 3:30 PM, when course compleWLRQFHUWLÂżFDWHVZLOOEHGLVWULEXWHG Registration: 7:45 AM â€“ 8:30 AM Morning Lecture: 8:30 AM â€“ 10:00 AM FOOD ADDICTION, APPETITE, and OVEREATING z New Developments in the Neurobiology of Food and Addiction. z The Brain Chemistry of Overeating. Hunger and Neurotransmitters. z Palatable or Addictive? Can a Doughnut Act Like a Drug? z Hooked. How Sugar, Salt and Fat Can Highjack the Brain. Who is At Risk? z Sugar Blues: Stress, Depression and Junk Food. z The Craving Brain: Recalibrating Brain Chemistry to End the Cycle of Food Addiction. Food, Breathing, and Mindfulness. z A Poor Maternal Diet: Programming the Next Generation to Become Hooked on Junk Food and Overeating. Mid-Morning Lecture: 10:00 AM â€“ 11:30 AM OBESITY z What Causes Obesity? Parallels with Addiction? Hormonal Imbalance? Poor Gut Health? New Research. z Appetite Suppression. Calories: Fat vs. Carbs. What Really Matters? z Diet Controversies: The Clash of Nutritional Ideologies. Prebiotics and Probiotics: What Role Might They Play? z Popular Diets: Paleo, Vegan, Ornish, Mediterranean: What Does the Science Tell Us? z Sleep and Food Craving. Sleep Tight, Donâ€™t Let the Cravings Bite. z Brown Fat: The Bodyâ€™s Own Weapon Against Obesity? Exercise to Promote â€œFat Browning?â€? z Pharmacotherapy for Obesity: Is There Anything New That Works? Antibiotics and Weight Gain? Lunch: 11:30 AM â€“ 12:20 PM Afternoon Lecture: 12:20 PM â€“ 2:00 PM DIABETES z Battling the Expanding Diabetes Epidemic. What Does it Take Actually to Cure Diabetes? z Fatty Liver to Fatty Pancreas to Beta Cell Failure. Can We Prolong the Beta Cellâ€™s Life? z Diabetes and Cognition: Type 3 Diabetes. z 7KH/LQN$PRQJ$OWHUHG*XW%DFWHULD,QĂ€DPPDWLRQDQG'LDEHWHV z Periodontal Preventive Medicine. The Mouth as â€œthe Gateway of the Body.â€? Interrelationships among Oral Health, Diabetes, and Other Chronic Diseases. z Gastric Bypass to Reverse â€œDiabesityâ€?: Is it Worth the Risks? Can it Reset Metabolism? Post-Surgery â€œAddiction-Transferâ€? Syndrome: Why Might Some Turn to Alcohol and Drugs? Mid-Afternoon Lecture: 2:00 PM â€“ 3:20 PM z Exercise: The Greatest Return on Investment Against Diabetes, Obesity, and Food Addiction. z Sleep: Late to Bed, Late to Rise â€“ Unwise for Diabetics? Sleep Apnea and Diabetes. z Pharmacologic Options for Diabetes: :HLJKLQJWKH%HQHÂżWVYVWKH5LVNV5ROHRI(DUO\$JJUHVVLYH3KDUPDFRORJLF7KHUDS\&RQFHSWRI0HWDEROLF0HPRU\ Evaluation, Questions, and Answers: 3:20 PM â€“ 3:30 PM 6 CONTACT HOURS / www.biomedglobal.com
MEETING TIMES & LOCATIONS LONDON, ON
Tue., Nov. 10, 2015 8:30 AM to 3:30 PM Best Western Lamplighter Inn 591 Wellington Rd. S London, ON
Thu., Nov. 12, 2015 8:30 AM to 3:30 PM Courtyard Toronto 7095 Woodbine Avenue Markham, ON
CHEQUES: $109.00 (CANADIAN) with pre-registration. $134.00 (CANADIAN) at the door if space remains. CREDIT CARDS: Most credit-card charges will be processed in Canadian dollars. Some charges will be in U.S. dollars at the prevailing exchange rate. Note: some Canadian banks may add a small service charge for using a credit card. The tuition includes all applicable Canadian taxes. At the seminar, participants will receive a complete course syllabus. Tuition payment receipt will also be available at the seminar.
7KLVSURJUDPLVGHVLJQHGWRSURYLGHQXUVHVZLWKWKHODWHVWVFLHQWLÂżFDQG clinical information and to upgrade their professional skills. Numerous registered nurses in Canada and the United States have completed these courses. This activity is co-provided with INR. This activity is co-provided with INR. Institute for Natural Resources (INR) is an approved provider of continuing nursing education by the Virginia Nurses Association, an accredited approver by the American Nursesâ€™ Credentialing Centerâ€™s Commission on Accreditation.
Pharmacists successfully completing this course will receive FRXUVHFRPSOHWLRQFHUWLÂżFDWHV%LRPHGLVDFFUHGLWHGE\WKH$FFUHGLWDtion Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. The ACPE universal activity number (UAN) for this course is 0212-9999-15-002-L01-P. This is a knowledge-based CPE activity.
Biomed, under Provider Number BI001, is a Continuing Profes- Provider sional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDâ€™s) and dietetic technicians, registered (DTRâ€™s) will receive 6 hours worth of continuing professional education units (CPEUâ€™s) for completion of this program/materials. Continuing Professional Education Provider Accreditation does not constitute endorsement by CDR of a provider, program, or materials. CDR is the credentialing agency for the Academy of Nutrition and Dietetics (AND).
&RXUVHFRPSOHWLRQFHUWLÂżFDWHVZLOOEHGLVWULEXWHGWRSV\FKRORJLVWV completing this program. This activity is co-provided with INR. INR is approved by the American Psychological Association to sponsor continuing education for psychologists. INR maintains responsibility for this program and its content.
This activity is co-provided with INR. Social Workers completing this SURJUDPZLOOUHFHLYHFRXUVHFRPSOHWLRQFHUWLÂżFDWHV7KLVSURJUDPLVDSSURYHG by the National Association of Social Workers (Provider #886502971-2437) for 6 social work continuing education contact hours.
Dr. Laura Pawlak (Ph.D., M.S.) is a full-time biochemist-lecturer for INR. Dr. Pawlak undertook her graduate studies in biochemistry at the University of Illinois, ZKHUH VKH UHFHLYHG KHU PDVWHUV DQG GRFWRUDO GHJUHHV $XWKRU RI VFLHQWLÂżF publications and many academic books, she conducted her postdoctoral research in biochemistry at the University of California San Francisco Medical Center. On such subjects as brain biochemistry, geriatric care, pharmacology, womenâ€™s health issues, and nutrition, Dr. Pawlak frequently speaks to audiences of health professionals. Biomed reserves the right to change instructors without prior notice. Every instructor is either a compensated employee or independent contractor of Biomed.
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Participants completing this course will be able to: characterize the neurobiology of food and addiction. describe potential causes of, and treatments for, food addiction and obesity. explain how excess body fat accumulation contributes to the development of type 2 diabetes. characterize the role of an altered gut microbiome, poor oral health, and sleep curtailment in the development of obesity and type 2 diabetes. outline interventions to manage, and potentially reverse, type 2 diabetes describe how the information in this course can be utilized to improve patient care and patient outcomes. describe, for this course, the implications for nursing, dentistry, mental health, and other health professions.
SPONSOR %LRPHGLVDVFLHQWLÂżFRUJDQL]DWLRQGHGLFDWHGWRUHVHDUFKDQGHGXFDWLRQLQVFLHQFH and medicine. Since 1994, Biomed has been giving educational seminars to Canadian health-care professionals. Biomed neither solicits nor receives gifts or grants from any entity. 6SHFLÂżFDOO\%LRPHGWDNHVQRIXQGVIURPSKDUPDFHXWLFDOIRRGRULQVXUDQFHFRPSDQLHV Biomed has no ties to any commercial organizations and sells no products of any kind, except educational materials. Neither Biomed nor any Biomed instructor has a PDWHULDORURWKHUÂżQDQFLDOUHODWLRQVKLSZLWKDQ\KHDOWKFDUHUHODWHGEXVLQHVVRUDQ\ other entity which has products or services that may be discussed in the program. Biomed does not solicit or receive any gifts from any source and has no connection with any religious or political entities. Biomedâ€™s telephone number is: (925) 602-6140. Biomedâ€™s fax number is: (925) 363-7798. Biomedâ€™s website is, www.biomedglobal.com. Biomedâ€™s corporate headquartersâ€™ address is: Biomed, P.O. Box 5727, Concord, CA 94524-0727, USA. Biomedâ€™s GST Number is: 89506 2842.
There are four ways to register: Online: www.biomedglobal.com By mail: Complete and return the Registration Form below. By phone: Register toll-free with Visa, MasterCard, American ExpressÂŽ, or DiscoverÂŽ by calling
1-888-724-6633. By fax:
(This number is for registrations only.) Fax a copy of your completed registration formâ€” including Visa, MasterCard, American ExpressÂŽ, or DiscoverÂŽ Numberâ€”to (925) 687-0860.
For information about seminars in other provinces, please call 1-877-246-6336 or (925) 602-6140.
REGISTRATION INFORMATION Individuals registering by Visa, MasterCard, American ExpressÂŽ, or DiscoverÂŽ will be charged at the prevailing exchange rate. If the credit card account is with a Canadian bank, the USA tuition will be converted into the equivalent amount in Canadian dollars (approximately $109.00) and will appear on the customerâ€™s bill as such. The rate of exchange used will be the one prevailing at the time of the transaction. Please register early and arrive before the scheduled start time. Space is limited. Attendees requiring special accommodation must advise Biomed in writing at least 50 days in advance and provide proof of disability. Registrations are subject to cancellation after the scheduled start time. A transfer at no cost can be made from one seminar location to another if space is available. Registrants cancelling up to 72 hours before a seminar will receive a tuition refund less a $35.00 (CANADIAN) administrative fee or, if requested, a full-value voucher, good for one year, for a future seminar. Other cancellation requests will only be honored with a voucher. Cancellation or voucher requests must be made in writing. If a seminar cannot be held for reasons beyond the control of the sponsor (e.g., acts of God), the registrant will receive free admission to a rescheduled seminar or a full-value voucher, good for one year, for a future seminar. A $35.00 (CANADIAN) service charge applies to each returned cheque. Nonpayment of full tuition may, at the sponsorâ€™s option, result in cancellation of CE credits issued. $IHHZLOOEHFKDUJHGIRUWKHLVVXDQFHRIDGXSOLFDWHFHUWLÂżFDWH)HHV subject to change without notice.
REGISTRATION FORM Tue., Nov. 10, 2015 (London, ON) Wed., Nov. 11, 2015 (Toronto, ON)
Thu., Nov. 12, 2015 (Markham, ON)
For information about seminars in other provinces, please call 1-877-246-6336 or (925) 602-6140
Please print: Name: Profession: Home Address: Professional License #: City: Province: Postal Code: Lic. Exp. Date: Home Phone: ( ) Work Phone: ( ) Employer: Please enclose full payment with registration form. Check method of payment. E-Mail: QHHGHGIRUFRQÂżUPDWLRQ UHFHLSW
Check for $109.00 (CANADIAN) (Make payable to BIOMED GENERAL) Charge the equivalent of $109.00 (CANADIAN) to my Visa MasterCard American ExpressÂŽ DiscoverÂŽ Most credit-card charges will be processed in Canadian dollars. Some charges will be in U.S. dollars at the prevailing exchange rate.
Card Number: Signature:
(enter all raised numbers)
(Card Security Code)
Please check course date:
HOW TO REGISTER
REGISTERED NURSES (RNs), REGISTERED PRACTICAL NURSES (RPNs), & LICENSED PRACTICAL NURSES (LPNs)
Wed., Nov. 11, 2015 8:30 AM to 3:30 PM The Old Mill 21 Old Mill Rd. Toronto, ON
Please return form to:
Suite 228 3219 Yonge Street Toronto, Ontario M4N 2L3 TOLL-FREE: 1-877-246-6336 TEL: (925) 602-6140 FAX: (925) 687-0860
HOSPITAL NEWS SEPTEMBER 2015