The miniaturization of medical devices
Healthcare delivery in remote communities
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www.hospitalnews.com DECEMBER 2016 EDITION | VOLUME 29 | ISSUE 12
INSIDE Evidence Matters ................................. 5 From the CEOâ€™s desk .......................... 11
Overview of advancements and trends in healthcare in 2016 and a look ahead at trends and advancements in health care for 2017. An examination of how hospitals are improving the quality of services through accreditation. An examination of safe and effective use of medications in hospitals and clinical pharmacology.
Trends in Transformation................... 14 Nursing Pulse ..................................... 16 Safe Medication .................................23 Careers ...............................................23
Robots in medicine Nine exciting facts Story on pages 12 & 13
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(left) The Reveal LINQ™ Insertable Cardiac Monitor (ICM) is a miniaturized heart monitor designed to help physicians quickly and accurately diagnose irregular heartbeats. (above) Medtronic Micra™ Transcatheter Pacing System is cosmetically invisible and small enough to be delivered through a catheter and implanted directly into the heart.
The future of healthcare is mini By Melicent Lavers-Sailly early a decade ago, Medtronic set out to revolutionize medical devices, to shrink them, by up to 90 per cent. These implantable devices make a big difference by being incredibly small. “We didn’t want to make them small for “small’s sake,” but to make them smaller and less invasive while providing the same or better therapy for patients,” says Paul Gerrish, director of technology at the Medtronic facility in Tempe, Arizona, where much of the miniaturization work took place. “People were saying that we were defying the laws of physics,” recalls Mark Phelps, senior program director and a key leader of the miniaturization team. “They said it wasn’t possible.” Using the same technology that compressed computing into the palm of your hand, micro-electronics experts in Arizona, along with designers, engineers and
HOSPITAL NEWS DECEMBER 2016
medical experts in Minnesota and elsewhere, found they could reinvent medical devices, using just a fraction of the space. But these doubts proved wrong. Thanks to micro-electronics, ultra-lowpower medical devices now use less energy when turned on than a smartphone does when turned off, allowing them to be much smaller in size. Two devices that highlight the trend towards miniaturization include an insertable cardiac monitor and the world’s smallest pacemaker.. “These devices are maintaining the level of performance that we have seen in on our larger systems,” says Charles Gordon, senior design manager. “And in some ways there’s even more intelligence in them in certain aspects.” The first of those high performing devices are beginning to reach patients. The Reveal LINQ™ Insertable Cardiac Monitor (ICM) is a miniaturized heart monitor designed to help physicians
By making things small enough, what we’re able to do is dramatically change the procedure of how these devices are used, to make them much less invasive which is better for the patient quickly and accurately diagnose irregular heartbeats (cardiac arrhythmias), which can cause fainting or stroke. Reveal LINQ received Health Canada licence in March 2014. Currently, it is the smallest cardiac monitor available (~1 cm3) and has a 3-year battery life under normal use conditions. The first generation Reveal cardiac monitor was invented by a Canadian physician, Dr. George Klein in collaboration with Medtronic. Each year, six per cent of Canadians over the age of 10 experience syncope, the medical term for fainting, which can result in falls or even fatal accidents. In 2014 Keeley Daley, a three year old at the time, was rushed to emergency at Janeway Children’s Health and Rehabilitation Centre in St. John’s, Newfoundland and Labrador after falling down several times that afternoon without explanation. She then received a Reveal LINQ ICM. Six days later on the morning of December 25th, 2014 Dr. Templeton received an alert on her cell phone indicating Keeley’s heart had paused. This allowed Dr. Templeton to relate the young girl’s fainting to a problem with her heart.
At just one-third the size of a AAA battery, Reveal LINQ monitors patients’ hearts, just like Keeley’s, 24-hours-a-day, seven days a week for up to three years, on a battery that wouldn’t last three minutes powering a lightbulb. Medtronic has continued the deep miniaturization of their devices. In October 2016, the Medtronic Micra™ Transcatheter Pacing System (TPS) became the First Leadless Pacemaker Licenced in Canada. It is cosmetically invisible and small enough to be delivered through a catheter and implanted directly into the heart. Unlike traditional pacemakers, Micra TPS does not require leads (electrodes) or a surgical “pocket” under the skin and there are no visible signs of the device. Micra TPS responds to patients’ activity levels by automatically adjusting therapy. Currently, Micra TPS is the first and only leadless pacing system licenced for both 1.5 and 3 Tesla full-body magnetic resonance imaging scans, providing patients with continued access to these advanced imaging diagnostic procedures. Believe it or not, Micra TPS is no bigger than a large vitamin capsule. “By making things small enough, what we’re able to do is dramatically change the procedure of how these devices are used, to make them much less invasive which is better for the patient,” says Chris Zillmer, vice president of Research and Technology. Medtronic engineers believe it is still possible to make devices even smaller, perhaps up to ten times smaller than the miniaturized devices today. After all, we’ve H done it before. n Melicent Lavers-Sailly is the PR and Corporate Communications Manager at Medtronic.
CCSA commits to key role in addressing
opioid use At last month’s Opioid Summit, hosted by the Honourable Jane Philpott, federal Minister of Health, and the Honourable Eric Hoskins, Ontario Minister of Health and Long-Term Care, the Canadian Centre on Substance Abuse (CCSA) proudly signed the Joint Statement of Action to Address the Opioid Crisis, joining over 40 other organizations in a coordinated effort to change the course of opioid use and harms in Canada. The two-day conference and summit concluded with commitments to bring about the immediate change that is required. The issue is a complex one and no one level of government or organization can address it alone. It requires commitment and collective action to achieve immediate collective impact. In signing the Joint Statement of Action, CCSA committed to the following measures: • On a quarterly basis starting March 2017: reporting on the Joint Statement of Action by communicating regularly with, monitoring the progress of, and facilitating reporting by all members. • Starting immediately: working with Health Canada to engage stakeholders and identify new partners with clear accountability for action to reduce the harms associated with opioids and other problematic substance use. • Providing leadership and guidance to individual and collective efforts as part
The opioid crisis is a complex one and no one level of government or organization can address it alone.
of ongoing work related to the First Do No Harm strategy to address the harms associated with opioids and other psychoactive prescription drugs. • Promoting the inclusion of the newly developed Competencies for Healthcare Professionals Related to Addiction and Pain in licensing exams and educational programs and curricula. • By March 2018: assessing the effectiveness of clinical pathways to improve treatment for youth and older adults experiencing issues related to opioids and other psychoactive prescription drugs CCSA has long played the role of convener and connector. We will use our expertise to continue to coordinate collective efforts, connect partners, gather and share evidence, identify emerging is-
sues and address stakeholder needs as per our legislative mandate and as part of the health portfolio. In addition, the First Do No Harm Executive Council, which is responsible for providing guidance to CCSA on the facilitation, implementation and evaluation of the First Do No Harm strategy, commits to the following measures: • As stewards of the First Do No Harm strategy, providing ongoing guidance in the coordination, implementation and evaluation of the strategy’s recommendations. • Continuing its role of providing expertise and coordination in the complex areas of problematic substance use. • In collaboration with McMaster University, contributing to updating the Canadian Guidelines for Safe and Effective Use of Opioids for Non-Cancer Pain and contributing to the development of e-tools for prescribers (e.g., train-the-trainer modules, face-to- face delivery, tool kits). • By March 2017: producing a manuscript examining prescribing patterns for short- and long-acting opioids in Ontario using Institute for Clinical Evaluative Sciences data. • By November 2017: promoting the more effective identification and treatment of those addicted to opioids and promoting the resources to address opiH oid overdose. ■
More than 40,000 Canadians “Demanding a Plan” for seniors care The number of Canadians pressing for action to improve seniors care in Canada through the Canadian Medical Association (CMA) Demand a Plan campaign has surpassed 40,000 and continues to climb. “Behind every one of these supporters is someone – or someone’s loved one – who is not getting the high-quality seniors care he or she deserves,” says Dr. Granger Avery, the CMA President. “Canada needs a new national Health Accord that will help our healthcare system meet the needs of Canada’s growing and aging population.” The number of supporters adding their voice to the call for action at Demand a Plan has grown by over 25,000 since last fall’s federal election, when the CMA www.hospitalnews.com
launched the campaign to ensure the voices of Canadians would be heard on healthcare. The Demand a Plan site has also expanded to include real-life stories from supporters trying to navigate the healthcare system to get care for themselves or their loved one. “During the election campaign last fall Demand a Plan supporters got the issue of seniors care on the election agenda, but now Canadians want action in the form of new Health Accord,” adds Dr. Avery. The CMA recently released Improving the Health of all Canadians: A vision for the future, which provides six clear and actionable recommendations that should be part of the 2017 federal/provincial/territorial Health Accord:
• targeted extra funding as a “top-up” to the Canada Health Transfer for provinces and territories with more seniors; • coverage for highly expensive medication so that Canadians do not experience undue financial hardship if they are sick; • more ﬁnancial support for family caregivers by making tax credits refundable; • a national strategy for palliative and end-of-life care; • a coordinated home care plan so that healthy seniors can continue to live in their homes and get the support they need; and • key infrastructure investments to improve and provide more long-term care H for Canadians who need it. ■
Research: Have your say about neurodevelopmental disorders
For the first time in North America, the public, caregivers, and professionals who are interested in the well-being of people with neurodevelopmental disorders can shape research about their diagnosis, therapies, and care using the James Lind Alliance method. The Ontario Brain Institute (OBI), the Province of Ontario Neurodevelopmental Disorder (POND) Network, and the James Lind Alliance in Great Britain will conduct a public survey to help researchers and the organizations who fund them ensure their work focuses on the priorities of people who actually live with a neurodevelopmental disorder like autism, Down syndrome or ADHD.* The survey launched in November and is available for approximately three months. Anyone who wants to have their say can simply fill in the survey at: http://www. braininstitute.ca/survey . “Involving patients, caregivers, and health professionals in what research tries to discover is a new and vital direction in research and healthcare. Our mandate is to ensure that the people who benefit from research – the patients, their loved ones, and caregivers – have a real say in the questions it seeks to answer,” says OBI’s President and Scientific Director, Dr. Tom H Mikkelsen. ■
2016: Biggest health stories 1. Medical assistance in dying (MAID) legislation 2. Opioid crisis 3. Need for a national seniors strategy 4. Zika virus 5. Shortage of mental health 6. Epipen cost skyrockets 7. New Canadian Health Accord DECEMBER 2016 HOSPITAL NEWS
JANUARY 2017 ISSUE EDITORIAL DEC 7 ADVERTISING: DISPLAY DEC 16 CAREER DEC 20 MONTHLY FOCUS: Professional Development/Continuing Medical Education (CME)/ Human Resources:
Continuing Medical Education (CME) for health care professionals. Human resource programs implemented to manage stress in the workplace and attract and retain health care staff. Health and safety issues for health care professionals. Quality work environment initiatives and outcomes. + PROFESSIONAL DEVELOPMENT SUPPLEMENT
FEBRUARY 2017 ISSUE EDITORIAL JAN 11 ADVERTISING: DISPLAY JAN 20 CAREER JAN 24 MONTHLY FOCUS: Facilities Management and Design/ Health Technology/Greening Healthcare/Infection Control:
Innovative and efficient health care design, the greening of healthcare and facilities management. An update on the impact of information technology on health care delivery. Advancements in infection control. + INFECTION CONTROL SUPPLEMENT
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Strengthening the culture of
patient engagement By Dr. Joshua Tepper n September 2009 a man with stage IV renal cell cancer stood on a stage in the MaRS auditorium in Toronto, firmly said “gimme my damn data” and arguably signalled the start of a new era in healthcare in Ontario. That man was Dave deBronkart (e-Patient Dave) and he was delivering the keynote address at the Medicine 2.0 conference in which he focused on the need and right for patients to have access to their own health data so they could participate more fully in their own care. While deBronkart is a U.S. citizen his vision for e-patients (equipped, engaged, empowered and enabled) is one that has taken root in Ontario. Widespread access by patients to their medical records may still not be here, but deBronkart and other like-minded patients and health care providers make a persuasive case for more patient involvement in all facets of healthcare planning and delivery. What deBronkart expressed – and continues to express today – had also been reflected a year earlier by University of Toronto professor and Medicine 2.0 founder Dr. Gunther Eysenbach who stated, “the emergence of social networking platforms and applications such as Facebook or PatientsLikeMe, potentially combined with… personal health records… create new levels of patient participation, as well as unique and unprecedented opportunities for engaging patients in their health, healthcare, and health research…” What deBronkart and Eysenbach were describing seven years ago has grown organically over the years with work by organizations such as Patients Canada nationally and in Ontario with the Change Foundation PANORAMA panel. Integrating patient engagement into the health system has now been given a significant boost in Ontario with publication by Health Quality Ontario of a
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framework to help guide healthcare organizations in better involving patients in their own care and the healthcare system as a whole. The Patient Engagement Framework has been developed with the goal of helping create a strong culture of patient, caregiver and public engagement to support high quality healthcare. We believe the framework must be implemented system-wide to truly have an impact rather than just be reflected in certain centres of excellence.
Patients cannot be true partners in improving health care quality unless they have access to easy-to-understand health information to help make decisions While talk of patient engagement is ubiquitous today, few frameworks exist to help healthcare organizations and those who work within them to partner with those who use their services. Those guides that do exist tend to focus on the United States or other countries. This framework is designed specifically for Ontario. Our framework was based on an extensive consultation process over a sixmonth period with patient, caregivers and providers from different regions of the province and parts of the health system, taking into account the diverse needs and preferences of those using the system. It was also developed based on the most current research on patient engagement both in Canada and internationally. What we heard confirms what is being heard globally – there is a strong interest among patients to engage in
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their care and that patient participation is seen as necessary, not only in direct care, but at all levels of the system – healthcare organizations, Local Health Integration Networks (LHINs), and ministry levels included. The framework spells out guiding principles, domains of engagement, engagement approaches and enablers to help patient engagement happen. It begins by recognizing that the public and patients cannot be true partners in improving health care quality unless they have access to easy-to-understand health information to help make decisions, be it about their own care or to aid in planning programs or policies. From there the framework traces a spectrum of engagement from consultation to collaboration, to enhance the trust many patients already feel for their providers. Patient engagement is a concept we take very seriously. In addition to producing numerous tools as well as the framework to help all partners work together more effectively and to help patient advisors work productively, we use the parameters laid out in the framework in our own work. For instance, the recent Health Quality Transformation conference hosted by Health Quality Ontario was a #patientsincluded conference – meaning it met a number of conditions laid out to ensure patients are meaningfully involved in all aspects of planning the conference as well as having patients both as speakers and delegates at the meeting. This growing sophistication in building true partnerships in health is exactly what we hope to foster with the new framework. We urge you to read and H discuss it and share it with others. ■
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GPS locator technology for people with dementia By Barbara Greenwood Dufour ost of us enjoy going outside for a walk when the mood strikes – the same goes for those of us with dementia. However, because of their tendency to wander, people with dementia are often denied this simple pleasure. Wandering behaviour can manifest itself within the home, as pacing or other repetitive walking patterns; but it can also cause individuals to unexpectedly leave the home at any time of the day or night. Once outdoors, whether or not there’s a particular destination in mind, a person with dementia can easily become lost, even in familiar places. This puts them at increased risk of injury or death from traffic accidents, hypothermia, dehydration, falls, fractures, and drowning. Common methods for keeping people with dementia safe are less than ideal. They typically involve keeping them indoors using physical barriers, restraints, or sedatives. These methods can cause adverse effects, such as pressure ulcers, falls, and increased anxiety, not to mention the loss of the freedom to explore and interact with their community. The desire for a better way to manage the risks associated with wandering has led to the development of new technologies that aim to allow some people with dementia to be more independent. One such technology is the GPS locator device. These devices are carried or worn by care-receivers so that, when they go missing, caregivers or emergency responders can quickly pinpoint their location and return them home safely. These devices are available in a number of formats, such as special cellphones, watches, bands worn around the wrist or ankle, and insoles worn in the shoes. A GPS locator device works by transmitting a signal to a network of telecommunications satellites, which is
then relayed through a mobile phone network to a caregiver’s computer or mobile device, or to a call centre, revealing the care-receiver’s geographic coordinates. The device can also be programmed with virtual boundaries so that a notification is sent out when a care-receiver goes outside of a designated safe area. But are these devices effective? What are the risks? With new technologies, we often don’t know enough about them to answer these questions. But, CADTH can find out what is known. CADTH is an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures to find out what the evidence says. Its Horizon Scanning program identifies new and emerging technologies that are likely to have a sig-
nificant impact on healthcare in Canada and reports on what is known so far about these technologies. The Horizon Scanning program recently looked at the available evidence on GPS locator devices for people with dementia and found seven recent studies on the topic. The studies show promising results – people with dementia were able to be outside of their homes more often, and they did so without increasing their own anxiety or that of their caregivers. Three studies that also looked at the effectiveness of these devices for finding lost individuals reported a decrease in the time and resources (including police services) used. A key concern that has been raised about this device involves the loss of pri-
vacy. It puts the individual with dementia under constant surveillance – the caregiver able to track where the care-receiver is at any time. The benefits in terms of improved safety, freedom, and independence the devices can provide, however, might be worth the loss of privacy. Still, to ensure that people with dementia agree with this trade-off, they should be given the opportunity to discuss their preferences as soon after their diagnosis as possible, while they’re still able to make informed decisions. While the early evidence suggests that GPS locator devices could make a positive difference in the lives of people with dementia and those who care for them, all of the studies identified by CADTH Horizon Scanning program were small in scale and further evidence of the cost-effectiveness of this technology is needed. However, its potential to give those with dementia more freedom to explore their environment, get physical exercise, and interact with their community make this a technology to watch. If you’d like more information about CADTH’s Horizon Scanning report on GPS locator devices for people with dementia – or on a variety of other new and emerging devices, procedures, diagnostics, and other health interventions – visit cadth.ca/Horizon-Scanning. To learn more about CADTH, visit cadth.ca, follow us on Twitter: @CADTH_ACMTS, or talk to the Liaison Officer in your region: cadth.ca/Liaison-Officers. To suggest a new and emerging technology for CADTH review, please email us at HoriH zonScanning@cadth.ca. ■ Barbara Greenwood Dufour is a Knowledge Mobilization Officer at CADTH.
Renal Transplant Program receives prestigious accreditation By Alexandria Anderson
t. Joseph’s Healthcare Hamilton is now one of two hospitals in Canada to receive a prominent accreditation from the Royal College of Physicians and Surgeons of Canada for training physicians and surgeons in kidney transplantation. “Accreditation from the Royal College places St. Joe’s as a national leader in the education of future surgeons and physicians,” says Dr. Azim Gangji, Renal Transplant Fellowship Program Director, St. Joseph’s Healthcare Hamilton. “Our fellows learn under a very specialized and unique curriculum that allows them to practice transplantations at the top of their field.” St. Joe’s Renal Transplant Program is unique in Canada as it is one of the few complex transplant programs in the country that can do all forms of kidney trans-
Dr. Azim Gangji, left, Nephrologist at St. Joseph’s Healthcare, with transplant recipient Cassy St. Pierre, right. www.hospitalnews.com
plantation including high-risk. The educational program provides fellows with a highly formalized and dedicated teaching structure that offers excellent clinical exposure in a collaborative and innovative environment. The program also conducts leading-edge research to improve the lives of the one million Canadians who live with moderate to severe kidney disease. “To maintain accreditation, the Renal Transplant program will continually develop and innovate to ensure we not only meet, but surpass criteria set by the Royal College,” says Dr. Gangji. “Our curriculum is different from other programs out there as it is has a strong emphasis on education and the delivery of patient-centred care. Kidney failure patients have a very difficult life and as a kidney doctor you need to be able to provide care and support from a
social, emotional and medical perspective. We don’t just focus on the kidneys, but the entire person – that’s who we care for.” The Renal Transplant Program is the first Area of Focused Competence (AFC) accredited program at St. Joe’s. An accredited AFC program meets national standards in its ability to enhance the scope of practice of post-residency training. “We have tremendous support from the hospital that enables us to deliver this high quality education program. “It is an accomplishment that is truly due to team work, a strong collaboration between the physicians and St. Joe’s administration and cliniH cal and laboratory staff.” ■ Alexandria Anderson is a Public Affairs Specialist at St. Joseph’s Healthcare Hamilton. DECEMBER 2016 HOSPITAL NEWS
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Improving the safe use of medications By Kathy Boyle vidence shows that medication errors can lead to negative patient outcomes, including death. In Canada, as many as 24,000 adults die every year from adverse events in acute care settings – medication errors account for almost half of these. Hospital pharmacies are continuously implementing processes with checks and balances to help avoid such errors, but some are most effective when pharmaceutical manufacturers do their part. On September 27, 2016, pharmacists from across the country came together with representatives from more than 50 pharmaceutical companies at HealthPRO’s Transforming, Together event, to raise awareness of hospitals’ current needs, including two simple changes manufacturers can make to help safeguard patients:
1. Providing hospitals at least 60 days’ notice of product changes
Hospital pharmacies are increasingly automated, featuring a wide array of technology from robotics, automated packaging and labelling machines, to optical verifiers and compounding pumps. This automation is designed to enhance resource efficiencies and contribute to medication safety – however when changes are made to pharmaceutical products that interface with these technologies without sufficient notice, unexpected and sometimes serious consequences can occur, including medication errors.
Did you know To avoid some of these consequences, pharmacists are therefore requesting pharmaceutical manufacturers to provide them with at least 60 days’ notice of any changes that trigger the need for an impact assessment or a change to the hospital’s product and supply chain:
2. A barcode on a medication’s unit-of-use
Barcodes on a medication’s unit-of-use can help safeguard against errors at the most vulnerable stage of the medication use process – during administration to a patient. In fact, evidence shows that a scan verification of the medication at the bedside can help reduce patient error in hospitals by up to 41 per cent. Many of the commercial products delivered to hospitals today do have barcodes
on the external packaging, but not on the unit-of-use, the format that would ultimately be administered to a patient. The absence of this feature critical for verification, can introduce risk and the need for hospital pharmacy staff to assume the task of creating and applying barcodes, often a manual and time-consuming undertaking. During the Transforming, Together event, pharmacists conveyed the importance of applying a barcode on a product’s unit-of-use and the properties that make them compliant to GS1 Standards and functional within the hospital supply chain. Over the coming months, HealthPRO, on behalf of its pharmacy members, will collaborate with pharmaceutical companies, suppliers, industry associations and governments to drive this critical transformation forward.
For more information, please visit: www. H healthprocanada.com. ■ Kathy Boyle is Vice President, Pharmacy Services at HealthPRO Procurement Services Inc.
Seasons Greetings from your friends at OPSEU Souhaits de bonne année de vos collègues du SEFPO
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Families co-lead quality and safety improvements By Anastasia Georgakakos olland Bloorview Kids Rehabilitation Hospital is fully partnering with families in quality and safety improvements as part of our accreditation preparedness process through an innovative engagement framework. “As a leader in client and family centred care, we not only want to meet the new accreditation requirements with respect to partnering with families, but exceed them,” says Laura Oxenham- Murphy, Manager of Quality at Holland Bloorview. Accreditation Canada is now requiring healthcare organizations to partner more fully with patients and families throughout all of their standards. The innovative framework embeds a total of 16 family leaders in all of the accreditation working groups across the hospital, ensuring any quality and safety assessments and decisions are made with their insights, expertise and lived experiences. The hospital also established the Family Leader Accreditation Group (FLAG) as part of the framework. Family leaders who sit on the accreditation working groups come together quarterly through FLAG to update each other on quality and safety initiatives, and to support and guide each other through the process. “As family leaders we are able to share our lived experiences and use a check and balance like system to align Holland Bloorview standards and services with client and family perspectives,” says Adrienne Zarem, family leader and chair of FLAG.
Holland Bloorview Kids Rehabilitation Hospital youth leaders Nikoletta Erdelyi, Emma Evans, Cristina Malana and Jeffrey Man (L-R) participated in patient safety training as part of the Patient Safety Education Program (PSEP) –Canada. In order to ensure families and staff were successful in our accreditation partnership, Holland Bloorview provided both groups with tools and training. The hospital developed toolkits outlining the purpose of the partnership and highlighting everyone’s roles and responsibilities to ensure families and staff worked together as a cohesive unit. In addition to the toolkits, Holland Bloorview provided orientation and training sessions to staff and families about how to effectively engage and partner on the accreditation teams. This included supporting the staff leads in providing the right type and amount of background information about quality and safety processes to families, so they could meaningfully participate in discussions and decision making.
FLAG members are now using their expertise beyond Holland Bloorview walls to inspire and support other families to get involved in quality and safety initiatives in healthcare. Hospital leads and FLAG member Alifa Khan partnered with the Canadian Patient Safety Institute (CPSI) and master facilitators to update the Patient Safety Education Program (PSEPCanada) existing learning modules. The updated modules reflect the patient and family perspective and are designed for patients and families to actually deliver the program and train other patients and families to deliver the program. Family and youth leaders in partnership with Holland Bloorview staff recently delivered the program to other staff, and are aiming to train over 200 patients and families in the next few years.
This peer-to-peer training model aims to help build capacity among patients and families to make our health system better and safer, and support the next generation of healthcare advocates. This model also represents a culture shift in patient safety that acknowledges how critical patient and family voices are in improving our health system. Adrienne Zarem and Alifa Khan, who took key leadership roles in FLAG and updating the PSEP-Canada modules respectively, recently received an Honourable Mention at the Patient Safety Champion Awards presented by HealthCareCAN and CPSI for exemplifying the spirit of collaborations and engaging patients and families in patient safety. “Our partnerships have provided us the foundations that other organizations, sectors and health systems can model,” says Sonia Pagura, Senior Director, Quality, Safety and Performance. Through family leadership groups and education programs like these, in combination with commitment towards cocreating change, Holland Bloorview continues to keep patient and family centred care at the heart of everything it does – ensuring that we not only meet the required standards of accreditation, but transform and lead health system wide improvements to quality and safety for patients H and families. ■ Anastasia Georgakakos is a Communications Assistant at Holland Bloorview Kids Rehabilitation Hospital.
DECEMBER 2016 HOSPITAL NEWS
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Breaking ground on the first hospital to be built in the city of Vaughan. The hospital, once completed, will provide state-of-the-art healthcare and positive outcomes for patients and their families.
Modernizing Ontario’s hospitals By Jamie Crawford-Ritchie n 2005, Infrastructure Ontario was tasked with helping to tackle the infrastructure deficit in Ontario. Every year we work with our partners to modernize Ontario’s hospitals and improve Ontarians’ access to healthcare across the province. This year was no different. Thanks to the support of our healthcare partners we have been able to help provide the people of Ontario with new emergency rooms, cancer treatment centres, hospices, operating rooms and more. Additionally, we are helping hospitals in communities across the province to improve wait times, increase access to important healthcare services and bring patient care closer to home. Modern hospitals can provide: more automated facilities, modern diagnostic equipment, expanded emergency services, updated infectious disease containment systems and more. Prior to Infrastructure Ontario’s inception, the average age of an Ontario hospital was 42 years! Today, modernizing hospitals in Ontario to improve access to healthcare in the province is an important part of what we do. The past year brought with it celebrations of major milestones for hospitals across Ontario, such as:
Mackenzie Vaughan Hospital In October, construction began on Mackenzie Vaughan Hospital. This is the first hospital to be built in the city of Vaughan, and the first new hospital to be built in York Region in the last 30 years. Once completed, the new hospital will include: A state-of-the-art emergency department, modern surgical services and operating rooms, advanced diagnostic imaging, specialized ambulatory clinics and intensive care beds and approximately 90 per cent single occupancy acute-care patient rooms for infection prevention and control. It will also be the first hospital in Canada to feature fully integrated HOSPITAL NEWS DECEMBER 2016
The new Peel Memorial Centre for Integrated Health and Wellness reached substantial completion in October of 2016. “smart” technology, which features systems and medical devices that can speak directly to one another to maximize information exchange. Etobicoke General Hospital In May, construction began on the new Etobicoke General Hospital Phase 1 Patient Tower. The project, involving the construction of a new four-storey wing, will add approximately 250,000 square feet of space to the existing facility and house the services most urgently needed by the Etobicoke community. Milton District Hospital In June, Milton District Hospital reached its highest point of construction, a major construction milestone, also known as a “topping-off”. Through this expansion, patients in Milton will benefit from expanded emergency and surgical services, medical and surgical inpatient units, critical care, maternal newborn, diagnostic imaging and support services. Peel Memorial Centre for Integrated Health and Wellness In October, the Peel Memorial Cen-
tre for Integrated Health and Wellness reached substantial completion. The new facility, located in Brampton, will house a number of clinical services such as: urgent care, diagnostic imaging services, mental health programs and medical/surgical services focusing on chronic disease management. The building will be open to patients in February 2017 and be fully operational in April 2017. The flexible design of the new hospital is in line with modern approaches to health care: fully accessible hallways, bright patient spaces and a welcoming environment for patients, staff and visitors.
CAMH Phase 1C Redevelopment In February, Infrastructure Ontario and the Centre for Addiction and Mental Health (CAMH) issued a request for proposal for the CAMH Phase 1C redevelopment project. This project will see the construction of two modern hospital buildings along Queen Street West in To-
ronto that will integrate innovative mental health treatment, research and education facilities with retail spaces, parks and the surrounding neighbourhood. Groves Memorial Hospital In June, Infrastructure Ontario and Groves Memorial Community Hospital issued a request for proposal to design, build and finance a new hospital in Aboyne, Ontario. This new hospital will replace the existing Groves Memorial Community Hospital in Fergus. Michael Garron Hospital (Formerly Toronto East General Hospital) In June, Infrastructure Ontario along with Michael Garron Hospital (formerly Toronto East General Hospital), a division of Toronto East Health Network, began the competitive bidding process and issued a request for qualification for a team to design, build and finance the new patient care tower project at the hospital. The project involves the construction of a new eight-story patient care tower and three-story podium, as well as demolition and selective renovations to the existing facility. Michael Garron Hospital’s redevelopment project will enable the delivery of efficient, accessible, high-quality patient care, while replacing some of the oldest spaces within the hospital. West Park Healthcare Centre In September, Infrastructure Ontario and West Park Healthcare Centre issued a request for qualifications for a team to design, build, finance and maintain the hospital redevelopment project in Toronto. This is the first step in a competitive bidding process and the next step on the path towards the construction of a new hospital building, providing inpatient, outpatient and outreach services to meet future demands for rehabilitative healthH care in Ontario. ■ Jamie Crawford-Ritchie is a Communications Associate at Infrastructure Ontario. www.hospitalnews.com
YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY
How a career in military medicine is influencing healthcare delivery in remote Ontario communities Joshua McNamara s a trauma surgeon and Colonel in the Canadian Forces, Dr. Homer Tien gained a unique perspective on the challenges of delivering trauma care in isolated environments under difficult circumstances. After a career spent serving as a General Surgeon and Medical Officer in locations such as Afghanistan, Bosnia and Herzegovina, Croatia, Myanmar and the Golan Heights, Dr. Tien retired from the forces in 2014 and joined Ornge, Ontarioâ€™s provider of air ambulance and related services, as Chief Medical Officer. One immediate focus: the dozens of fly-in only communities across Ontarioâ€™s far north where patients receive care in nursing stations. â€œIn the military, we treat patients in remote locations where there are limited resources,â€? says Dr. Tien. â€œWe have to think about providing better support to the healthcare providers in those Ontario communities, prior to transport. I hope our strategies to improve our service to the north and how we support our stakeholders will reflect this.â€? Dr. Tien joined Ornge from Sunnybrook Health Sciences Centre where he was Medical Director for the Tory Regional Trauma Centre, Canadaâ€™s largest trauma unit. After more than a year on the job, Dr. Tien has been looking to apply much of what he has learned to the field of medical transport â€“ particularly across the expanse of Ontarioâ€™s north. Ornge paramedics perform approximately 18,000 patient-related transports annually in its fleet of helicopter, airplane and land ambulances, with approximately two thirds of these transports taking place north of Sudbury. â€œAs healthcare delivery evolves in Ontario, so does the role we play in serving northern communities,â€? says Dr. Tien. â€œTransport and access to care become even more important when patients need to get to a tertiary hospital for specialized medical care.â€? Dr. Tienâ€™s work complements other northern-focused initiatives underway at Ornge. Ornge added an 11th AW139 helicopter based in Moosonee to serve the local community and surrounding communities along the James Bay Coast. Ornge has also trialed the use of Night Vision Goggles (NVG) technology at its Sudbury base. NVGs are light intensifiers, where ambient and cultural light is gathered and amplified to provide enhanced vision for the pilots, allowing them to â€œseeâ€? their surroundings clearly, even in almost total darkness â€“ a common circumstance in the north where there are frequent nighttime trips across
Thereâ€™s always room for improvement,â€? says Dr. Tien. â€œWe thank our stakeholders for providing us with their feedback.
Dr. Homer Tien is the Chief Medical Officer at ORNGE. largely unpopulated areas and landings in communities where there is little cultural lighting. The trial was deemed a success, and the organization is preparing to roll out the technology to its entire helicopter fleet across the province. In addition, Ornge has been working with Cochrane District EMS, hospitals along the Highway 11 corridor, and the trauma program at Health Sciences North to expand the use of modified scene response around Ontario using airplanes. This will allow for an expedited transport of patients directly to the HSN trauma centre. The goal of this initiative is to minimize the time from injury to definitive care among patients in the northeast and decrease morbidity and mortality. Dr. Tien believes there are also opportunities for the sharing of knowledge and education. To date, he has delivered a number of presentations to medical professionals in Health Canada-administered Nursing Stations during bi-weekly rounds on topics such as traumatic brain injuries, chest trauma, trauma overview, airway trauma and bleeding. â€œDelivering rounds for nursing stations allows us to work more closely with our healthcare partners and assist smaller centres,â€? says Dr. Tien. Ornge has also begun using the Ontario Telemedicine Network (OTN) to better advise northern health centres to collectively help care for patients effectively. Dr. Tien is also very interested in hearing from stakeholders â€“ our referring hospitals â€“ how Ornge can improve its service to them. In response, stakeholders have
been providing feedback on how Ornge can continue to help patients access the care they need expeditiously. Thereâ€™s always room for improvement,â€? says Dr. Tien. â€œWe thank our stakeholders for providing us with their feedback. As a result, weâ€™re looking at ways to minimize the information weâ€™re collecting about our patients from hospitals or nursing stations in order to improve the speed of our dispatch process. Weâ€™re also providing a rapid
estimated time of arrival (ETA) in the first call we have with health facilities.â€? With Orngeâ€™s evolving role, Dr. Tien believes there are more opportunities for Ornge to work with health care facilities in northern Ontario moving forward to analyze data for gaps and how to close them, providing advice on medical equipment H and assist in training or education. â– Joshua McNamara works in communications at ORNGE.
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ORNGEâ€™s new AW139 helicopter in Moosonee and the Pilatus PC-12 aircraft, which is also used to service northern communities. www.hospitalnews.com
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DECEMBER 2016 HOSPITAL NEWS
YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY
A case for the art of palliative care By Helen Reilly he careful attention Linda dedicates to each detail of her sculpture, brings a sense of peace and accomplishment to her face. Her smile and outlook reveal an optimism that does not reflect her reality – that she is coping with profound grief since the loss of her husband, after a brief illness, earlier this year. Linda considers herself fortunate to have access to Hospice Wellington’s Grief and Bereavement Art Therapy program. Since she and her husband moved to Guelph, Ontario less than a year before his diagnosis, she did not have a strong network to rely on for support following his death after a brief illness. Linda suggests it is contact with other grievers – people who truly understand what she is going through – that supports her through her journey. She is surprised by how invested she is in her sculpture as it takes shape week to week, with the therapeutic guidance of Nicole Fantin, Art Therapist, Hospice Wellington. “It’s like a magic combination that surprised me – there’s such a sense of accomplishment in it,” she says. Comparing her husband’s death in hospital to that of a family member’s recent death in hospice, Linda calls the two ‘polar opposites,’ saying the hospice’s home-like environment “makes the last period of time feel normalized – somehow, it takes away the fear,” she says.
Nicole Fantin, Art Therapist, Hospice Wellington works with individuals of all ages who have life-limiting illnesses. Through the hospice’s community hospice program, art therapy and other programming supports individuals receiving hospice palliative care, their families and caregivers throughout the grief and bereavement journey. Rami Shami, Director, Community and Volunteer Services, Hospice Wellington reinforces the fact that, “environment is the cornerstone of hospice palliative
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care,” suggesting it is the home-like environment and the support one receives in that environment – be it, in an individual’s own home or in a community hospice – that changes the experience of how we die. “It determines how our journey is navigated and experienced – but also, and importantly, how it is witnessed by others.” With only three in 10 Canadians having access to hospice palliative care in their communities when they need it, coverage across the country is inconsistent. As well, a lack of awareness regarding the services that constitute palliative care, where, how and when to access them, remains a barrier to care. Ontario’s Auditor General noted in her 2014 report that hospice beds were unevenly distributed and that 260 palliative care beds in hospices and hospitals across the province fell far short of the 1,350 beds required to cost-effectively meet the needs of individuals requiring palliative care. The Canadian Cancer Society’s Right to Care: Palliative Care for All Canadians report, published earlier this year, suggests improvements are needed in Canada’s costly and inconsistent patchwork of palliative care which inadequately supports individuals and families and does not support the health system’s sustainability. John Fraser, MPP, Ottawa South & Parliamentary Assistant to Ontario’s Minister of Health and Long Term Care, authored the Palliative and End-Of-Life Care Provincial Roundtable Report which is helping Ontario develop a comprehensive strategy on palliative and end-of-life care – one that is focused on supporting families, caregivers and ensuring access to coordinated quality care where patients want to receive it. Given John Fraser’s whole-hearted dedication to this work, Linda says, “aren’t we lucky to have him?” Fraser’s report laid the groundwork for a Ministry decision to dedicate $75 mil-
lion to hospice palliative care over three years to improve community-based hospice palliative care services, supporting 20 new hospices across Ontario and increasing funding to existing facilities. The funding increases support for caregivers, helping individuals remain at home or in the community longer, promotes advance care planning and establishes the Ontario Palliative Care Network to advance patient-centred care and develop provincial standards to strengthen services. Community-based residential hospice programs and visiting hospice programs are available free of charge to individuals with life-limiting illness and their families across the province. Relying on donors and volunteers, hospice offers specialized care wherever individuals wish to receive it. The cost of care in a community hospice, which is covered by the Ministry is $460 per day (excluding drug costs) which is dramatically less than the $1,100 provincial average daily cost of providing palliative care in an acute care hospital bed. Individuals can also receive this specialized care in the comfort of their own home, at a cost to the Ministry of under $100 per day, where at-home care is provided and available. The late Dr. Dorothy Ley, an early leader of hospice in Ontario, believed spiritual care and the role of volunteers were at the heart of hospice. Volunteers play an essential and critical role in the delivery of care, regardless of the setting. As such, the province is also partnering with Hospice Palliative Care Ontario to provide training that will build volunteer capacity throughout the province. It is through individuals like Linda that we learn about the value of hospice palliative care for the sustenance of our health care system, for improved quality of life for individuals with life-limiting illness, H their caregivers and families. ■ Helen Reilly is freelance writer. www.hospitalnews.com
From the CEO's Desk 11
Using evidence-based practice to
improve mental healthcare By Carol Lambie
dvancing understanding and improving lives is Waypoint’s motto. To do that, we have to be bold, innovative and forward-thinking; and we have to be treating our patients with therapies that are rooted in science. In healthcare, including mental healthcare, it is becoming increasingly important to provide evidence-based services for patients and clients to support achieving the most positive outcome. We can’t keep doing the same thing we’ve always done, or we’ll keep getting the same result. Waypoint has a rich 40-year history of research, with nearly all of it focused on forensic mental health. In 2011, we began a formal partnership with the University of Toronto, and in 2013 launched the Waypoint Research Institute paving the way to expand the research focus into evidencebased practice and four key themes of risk factors and assessment, treatment and transitions, policy, and knowledge translation.
Translating research knowledge into practice typically takes around 17 years, this is a gap we should all be trying to bridge. Evidence-based practice is defined by the Canadian Psychological Association as psychological treatments that involve the conscientious, explicit and judicious use of the best available research evidence to inform each stage of clinical decision-making and service delivery. If you were a patient or a family member of someone in a mental health hospital, wouldn’t you want us to be using the latest research to inform the care you receive? The Waypoint Research Institute recently refreshed its strategic plan to build on the strengths of the previous plan, increase integration of research excellence with clinical services and improve clinical care. The plan now includes a major focus on strengthening knowledge translation and providing expertise and support to our clinical programs in the identification, implementation, and evaluation of evidencebased practice. One of the ways we support this is by hosting an annual Waypoint Research Institute conference. The theme of the fourth such conference held in April 2016 was Implementing Evidence Based Practices in Mental Health and Addictions. It was two full days featuring two keynote speakers and nearly 60 concurrent sessions looking at some of the challenges, strategies and successes in this regard. www.hospitalnews.com
With research telling us that translating research knowledge into practice typically takes around 17 years, this is a gap we should all be trying to bridge. Our research team has expanded over the years to include knowledge translation, as well as clinician-scientists who spend half their time undertaking research and the other half implementing that research to improve patient and client outcomes. With this shift in focus for the Waypoint Research Institute, we’ve been able to begin the process of evaluating our clinical programs to ensure we’re using evidencebased therapies. This work actually began back in 2007 when, under the leadership of Dr. Shari McKee, Waypoint’s concurrent disorders program transformed to include the most current and supported psychological practices for mental illness and substance use. More recently, our team of researchers evaluated our Acute Assessment program and validated it as a program effective in improving patient outcomes. This process is continuing and we will evaluate all of our clinical programs to ensure the care being delivered is evidence-based. Helping with this ongoing evaluation is the Waypoint Index of Clinical Improvement. The Index is a set of program outcome indicators developed from the InterRAI-MH data and tailored for each Waypoint clinical program, giving leaders and their teams a better understanding of service effectiveness and helping improve how we understand, monitor and meet patient needs. Of course, none of this work would have been possible without the expertise and leadership of Dr. Howard Barbaree, our vice-president of Research and Academics. Before joining Waypoint in 2010, Dr. Barbaree, an internationally recognized research psychologist, professor, author and editor, was the former head of the Law and Mental Health Program in the Department of Psychiatry at the University of Toronto and the former clinical director of CAMH’s Law and Mental Health program. Dr. Barbaree spent the last six years leading the integration of the hospital’s research, education and clinical activities, and identifying new academic partnerships. He also supported the development and recruitment of a research advisory committee and led the implementation of the original Research and Academics strategic plan as well as two subsequent revisions. Dr. Barbaree recently announced he will retire at the end of December. We wish him all the best and will miss his support for our ongoing focus on research and academics and his contribution to our senior leadership team. He leaves behind a rich and deep legacy and finding his successor will not be an easy task. His accomplishments are many and his commitment to our patients is remarkable.
Carol Lambie is President and CEO, Waypoint Centre for Mental Health Care. In this challenging health’care landscape, Waypoint is continually trying to improve the interventions so as to provide the best, most responsible care for patients and clients while respecting and valuing staff. Mark your calendars for our next conference on May 15-17, 2017 at the Holiday Inn in Barrie Ontario where the theme
once again will be Implementing Evidence Based Practices in Mental Health and Addictions. Two keynote speakers have already been confirmed and the Call for Abstracts has a deadline of December 20, H 2016. ■ Carol Lambie is President and CEO, Waypoint Centre for Mental Health Care.
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DECEMBER 2016 HOSPITAL NEWS
YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY
Nine exciting facts about
medical robots By Dr. Bertalan Mesko
o you remember how Anakin Skywalker was seriously burnt and lost his legs in the third episode of Star Wars, The Revenge of the Sith? And do you also remember how robot surgeons did the best they could to save him? In the very near future, similarly amazing robots might come to healthcare to save our lives, too. Medical robots don’t only exist in sci-fi movies, they are coming to healthcare. Robots can support, assist and extend the service health workers are offering. In jobs with repetitive and monotonous functions they could even obtain the capacity to completely replace humans, freeing up healthcare professionals for other tasks. If medical professionals want to utilize them successfully, they should learn more about them. Here are the nine most exciting medical robot facts.
1) 70% drop in hospital-acquired infections due to Xenex Robot
Statistics of the Centers for Disease Control and Prevention show that in the United States 1 in every 25 patients will contract hospital acquired infections (HAIs) such as MRSA (methicillin-resistant Staphylococcus aureus) and C. diff (Clostridium difficile), and one in nine will die. In Canada, more than 200,000 patients get infections every year; more than 8,000 of these patients die as a result. The Xenex Robot might constitute the next level of hygiene. It allows for fast and effective systematic disinfection of any space within a healthcare facility. This helpful automatic tool destroys deadly microorganisms causing HAIs by utilizing special UV disinfection methodologies. The Xenex Robot is more effective in causing cellular damage to microorganisms than other devices for disinfection, thus the number of HAIs might be more
HOSPITAL NEWS DECEMBER 2016
effectively reduced. Westchester Medical Center reported a 70 per cent drop in Intensive Care Unit C. diff with the use of Xenex Robots.
2) Two Belgian hospitals “Hired” Pepper Robots as receptionists
Pepper, the 1.2 meter tall humanoid “social robot” will be “employed” as a receptionist in two Belgian hospitals. It’s a fascinating idea – because let’s be honest: there is not a single person who was not even once greeted by a grumpy receptionist during a hospital visit and got lost in a hospital due to information hastily provided by kind but tired nurses at the end of their shift. Pepper can recognize the human voice in 20 languages and can detect whether it is talking to a man, woman or child. Its skills enable Pepper to “work” as a receptionist in huge hospitals and to accompany visitors to the correct department so they
do not get lost while trying to see their loved ones. “Social robots” such as Pepper or the smaller Nao might also be used as assistance in exercise sessions and help children overcome their fears of surgery.
3) By 2020, surgical robotics sales are expected to almost double to $6.4 billion
What would you ask before undergoing an operation? You would ask for a successful procedure and for the doctor to be in his or her best shape, wouldn’t you? The da Vinci Surgical System helps ensure this: it enables the surgeon to operate with enhanced vision, precision and control. Thus it contributes greatly to a successful procedure. This robotic system features a magnified 3D high-definition vision system and tiny wristed instruments that bend and rotate far greater than the human hand. With the da Vinci Surgical System, surgeons operate through just a few small incisions.
The surgeon is 100 per cent in control of the robotic system at all times, and he or she is able to carry out more precise operations than previously thought possible. This industry is about to boom as recently reported.
Photo courtesy of In
YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY 4) 750,000 remote clinical encounters through Intouch Health
Imagine you are at home with your dad and he suddenly feels a strong headache, starts to feel dizzy and has a speech disorder which he has never experienced before. Of course you would immediately call an ambulance. But what if you live in a rural area or frontier town where it takes ages until help arrives? Intouch health and its telehealth network could help in such situations. Through the network patients in remote areas have access to high-quality emergency consultations for stroke, cardiovascular, and burn services in the exact time they need it. Moreover with telehealth, medical professionals in such towns and rural areas also have access to specialty services and patients can be treated in their own communities. Through this network, a “telemedical robot” has already established over 750,000 clinical encounters where it was not possible before.
5) TUG Robot able to carry around more than 400 Kilograms of medication
The TUG robot is the robust and muscular big brother of Pepper, who is able to carry around a multitude of racks, carts or bins up to 453 kilograms in the form of medications, laboratory specimens or other sensitive materials. The TUG is sent or requested using a touch screen interface and upon completing its “mission”, it returns to the charging dock for a sip of energy while it is loaded for the next job. And the benefits? These robots work around the clock, so fewer employees are necessary for the burdening nightshifts. Staff can spend more time with patients or assist nursing instead of transporting goods through the hospital. Moreover, nurses do not have to carry around heavy loads and can avoid related injuries.
6) Bear-shaped robot can lift patients out of bed 40 times a day
ntuitive Surgical Inc.
Riba or Robot for Interactive Body Assistance is somewhat similar to the TUG
robot, however it is used at homes with care patients who need assistance. Its Japanese version, the Robear is shaped as a giant, gentle bear with a cartoonish head. They both can lift and move patients in and out of bed into a wheelchair, help patients to stand, and to turn them to prevent bed sores as many times as you want. These robots not only promise to make up for the shortage of caregivers, but to save human personnel from having to carry out strenuous tasks, such as lifting patients out of bed 40 times a day.
7) Less than a millimeter sized Microbot delivers drugs through bloodstream
Remember the 1960s science fiction movie Fantastic Voyage, where a submarine and the people inside it were shrunk to microscopic dimensions and were injected into a person’s bloodstream? Now, reality has come one step closer to this scenario. Researchers from the Max Planck Institute for Intelligent Systems in Stuttgart have been experimenting with exceptionally micro-sized – meaning they are smaller than a millimeter – robots that literally swim through your bodily fluids and could be used to deliver drugs or other medical relief in a highly-targeted way. These scallop-like microbots are designed to swim through non-Newtonian fluids, like your bloodstream, around your lymphatic system, or across the slippery goo on the surface of your eyeballs.
8) Veebot draws blood in less than a minute
There is hardly any adult in the developed world who has never been the subject of a blood draw. Many have serious fears about it. On the one hand, it might
be pretty scary that it is carried out with a needle. On the other hand, sometimes it takes a lot of time and more than one attempt until the nurse or the phlebotomist finds the appropriate vein to carry out the procedure. Veebot, a blood-drawing robot helps with the latter and allows for speeding up of the unpleasant experience. With Veebot, the whole process takes about a minute, and tests show that it can correctly identify the best vein with approximately 83 per cent accuracy, which is about as good as an experienced human phlebotomist.
9) Cuddly animal-shaped PARO robot reduces stress for patients
It is widely known that pets and cute animals help to ease stress, to divert attention from pain and to reduce the feeling of loneliness. Unfortunately, not every hospital or extended care facility allows animals to live next to patients. AIST, a leading Japanese industrial automation pioneer offers a solution. PARO is an advanced interactive robot developed by AIST. It allows the documented benefits of animal therapy to be administered to patients in medical environments in the shape of a baby harp seal covered with soft artificial fur to make people feel comfortable, as if they are touching a real animal. This therapeutic robot has been found to reduce the stress factor experienced both by patients and H their caregivers. ■ Dr. Bertalan Mesko, The Medical Futurist, is a Healthcare Speaker, Author and consultant, physician, PhD in genomics and founder @ Webicina.com. This article is reprinted with permission from his blog medicalfuturist.com.
Photo courtesy of RIKEN
DECEMBER 2016 HOSPITAL NEWS
14 Trends in Transformation
Engaging, enabling and empowering By Mike Norman atients admitted to St. Thomas Elgin General Hospital (STEGH) from the Emergency Department can expect to be transferred to an inpatient unit less than an hour after doctors decide to admit them. Previously, it took, on average, four hours to move those patients into a bed, but because of its commitment to a culture of continuous quality improvement, STEGH is making major strides in improving patient flow and the patient experience. This transformational journey began in 2010, focusing on reducing Emergency Department (ED) wait times by looking at the entire patient journey from beginning to end. STEGH moved to number one out of 74 sites in the Pay for Results on this metric and remains there today, all while managing volumes which have increased from 38,000 ED visits per year to 51,500.
NYGH’s multidisciplinary palliative care team serves approximately 1,000 inpatient, 325 clinic, and 100 outreach patient visits every year.
Palliative Care program receives prestigious national designation By Elizabeth McCarthy hile under the care of staff and physicians from North York General Hospital’s (NYGH) Freeman Centre for the Advancement of Palliative Care, Pat (Patricia) Mackey wanted people to know that “palliative care is about finding energy and joy in your day, not focusing on the illness.” This explanation of palliative care by one of its own patients is what distinguishes NYGH’s palliative care program from the rest. Caring for the whole person, not just their symptoms, is a large part of the reason the Freeman Centre was recently designated a Leading Practice by Accreditation Canada. Every year hundreds of submissions are made to Accreditation Canada’s Leading Practices Database. Leading Practices must be creative and innovative, clientor family-centred, evaluated, sustainable, able to demonstrate successful results, and be adaptable by other organizations.
The review process is rigorous; only 35 to 40 per cent of submissions become Leading Practices. The Freeman Centre is the only adult palliative care program in Canada to be recognized in its entirety as a Leading Practice by Accreditation Canada. Established in 1999, the Freeman Centre is a patient- and family-centred program that provides an added layer of support to patients with advanced serious illnesses. Originally, it was a group of dedicated family physicians who identified the need for a community-based service to support palliative cancer patients who wished to die at home and their families. The Freeman Centre’s multidisciplinary team of physicians, advance practice nurses, nurses, social workers, researchers, chaplains, and other allied health professionals work with a patient’s family and care providers to deliver comprehensive inpatient, outpatient and home-based care.
Initially the Freeman Centre cared for patients with terminal cancer diagnoses. The program has since expanded over the last 16 years, and now includes palliative care consultations across NYGH for cancer and non-cancer illnesses. As well, outpatient services care for patients with advanced congestive heart failure (CHF) and respiratory illnesses. “Having access to comprehensive, highquality palliative care services improves a patient’s overall care and quality of life while decreasing the number of unnecessary emergency department visits and intensive care unit (ICU) admissions,” says Dr. Daryl Roitman, Director, Freeman Centre for the Advancement of Palliative Care, NYGH. “I am proud to work with such a dedicated group of people every day.” Accreditation Canada’s Leading Practices Database fosters the sharing of best practices between healthcare organizations. To date, the database includes over 1,000 practices recognized as being particularly innovative and effective in improving the quality of care. These practices are leading in a service delivery area, in a particular healthcare setting, or for a specific healthcare challenge. Some are ingenious in their simplicity. Often, they are implemented by organizations with limited resources, showing how innovative and creative strategies can achieve positive results at a minimal cost. “Congratulations to the team at North York General Hospital on receiving its second Leading Practice award,” says Leslee Thompson, Chief Executive Officer, Accreditation Canada. “This palliative care program is an innovative example of a multidisciplinary approach that optimizes the care experience for patients and families.” This is the second time a North York General program has received a Leading Practice designation. The Hip and Knee Integrated Care Collaborative was named a 2015 Leading Practice by Accreditation Canada for its model of care that supports patients needing hip and knee replacements along their entire journey with the H support of a nurse/patient navigator. ■ Elizabeth McCarthy is a Senior Communications Specialist at North York General Hospital.
HOSPITAL NEWS DECEMBER 2016
Clarity of why the organization exists, where it is going and how it will get there enables people to prioritize their actions, innovate and take risks with confidence. One team, one purpose
To fulfill STEGH’s vision of an excellent patient care experience every time, STEGH adopted a Lean philosophy and framework to guide staff, physicians and volunteers in everything they do. Clarity of why the organization exists, where it is going and how it will get there enables people to prioritize their actions, innovate and take risks with confidence. “We have five general corporate priorities and everything at the unit level drives one of them,” says Mary Stewart, Vice President, STEGH. “By building a community of problems solvers we are creating capability and empowering the people who are impacting the patient experience to be bold and innovative.” Key metrics, which are determined by the Quality Improvement Plan and the Board of Governors, are cascaded throughout the organization. The board-to-bedside metrics visualize how a team’s improvement initiatives impact their department huddle board performance metrics, as well as the Leadership and Board scorecards. “When I go and see what a team is working on during their huddle my first question to the manager is, ‘what is the problem you are trying to solve?” says Mary. “My next question is what corporate priority are you trying to reach?”
Standardizing the manager’s role
As part of Leader Standard Work, every manager facilitates a huddle during meeting-less mornings using a standardized script to engage their teams in continuous improvement. Continued on page 15 www.hospitalnews.com
Trends in Transformation 15
(left) Robin Mitchell, Coordinator, ED, leads the team huddle and reviews metrics with staff daily. (right) The hospital’s commitment to continuous quality improvement from boardroom to bedside is evident in how the Board of Governors functions as well. Continued from page 14 During the huddle, team members have the autonomy to decide which improvements take priority based on how the improvement will influence metrics from the bottom up. “Moving patients to the right level of care as soon as possible is one of our top priorities,” says Robin Mitchell, Coordinator, Emergency Department. “After missing our one-hour target by a few minutes several days in one week, we opened a continuous improvement (CI) ticket for ourselves.” A CI ticket is used to document a problem identified by a team member. If the team agrees that it is indeed an opportunity and data shows the problem truly exists, someone will be assigned to
champion it and come up with a solution, or test of change, using a problem solving model such as Plan-Do-Check-Act. “Staff and even patients can create a CI ticket, which we prioritize based on the high-level organizational goals,” says Robin. “After closing a ticket we can see the impact on our huddle board, the weekly leadership scorecard and over time we see it impacting the board scorecard, all of which are posted on the unit’s huddle board and visible to the entire team.” Having clear priorities on the unit also helps staff to prioritize their own tasks more effectively. “Units make sure they discharge patients as soon as they are ready to go,”
says Robin. “That creates bed capacity, allowing ED nurses to prioritize tasks related to transferring patients to the unit. In the past it took approximately five hours for the units to make a bed available. That delay created uncertainty for nurses around their priorities.”
Meaningful metrics drive improvement
“The hospital board supports the organization by setting stretch goals,” says Melanie Taylor, Chair of the Board of Governors, STEGH. “We don’t just monitor for the sake of monitoring, or pick metrics we are already doing well on. We’re not afraid of missing targets because that’s where we see the learning opportunities.”
The STEGH Lean Management System incorporates a clear strategic framework, executives spending time where the work is done, consistent standards for how work is done, and meaningful, highly visible metrics. The outcome is a community of problem solvers creating momentum by engaging in continuous quality improvement – Everybody, every day, everywhere. Transformation is an intentional journey in pursuit of perfection and while it may never be reached, excellence is H our goal. ■ Mike Norman is Manager, Quality and Process Improvement at St. Thomas Elgin General Hospital.
DECEMBER 2016 HOSPITAL NEWS
16 Nursing Pulse
Scope of practice limited for Ontario nurse practioners
Ontario is the only jurisdiction in Canada where NPs cannot prescribe controlled substances. By Daniel Punch
avid Free knew just what his dying patient needed. He needed a breakthrough dose of an opioid to relieve the intense pain caused by his terminal cancer. It was the same medication and dosage the man received earlier that day, and the same medication Free had prescribed numerous times for other patients as an NP practising in Maryland. But this wasn’t Maryland. It was Ontario. And unlike in Maryland, and nearly every other jurisdiction in North America, Ontario NPs cannot prescribe opioids. “I knew exactly what needed to be done, but I was restricted to having to get a verbal order from a physician to be able to do it,” Free recalls. Instead of easing his dying patient’s pain, Free spent the next hour trying to track down a physician to prescribe some relief. He couldn’t find one, and the patient suffered needlessly for nearly 90 minutes in the waning hours of his life until his next scheduled dose was due. Despite being able to prescribe most medications, Canadian NPs were long prohibited from prescribing drugs listed in the federal Controlled Drugs and Substances Act, including opioids and benzodiazepines. That all changed in 2012, when amendments to the Act gave NPs the authority to prescribe controlled substances. Provinces and territories needed only to alter their regulations to expand NPs’ scope, which all of them have done since – all except Ontario. When Free heard there were changes coming, he was working in the U.S. The Ontario native had moved south of the border in 2009 to take the NP program at the University of Maryland at Baltimore.
As an NP in Maryland, he practised to his full scope, prescribing opioids and other controlled substances to his palliative care patients. After completing his clinical doctorate, he moved back to Ontario in 2015 to become director of palliative care at a large hospital system, expecting he would soon be able to prescribe controlled substances in his home province. Instead, he has been frustrated by his inability to prescribe the pain medication his patients require. “It feels like it really cuts me off at the knees,” he says.
Prescribing is not just about giving people more opioids. In many cases, it’s about giving them less The Registered Nurses’ Association of Ontario (RNAO) has worked for years to get Ontario NPs authorized to prescribe controlled substances. There are more than 2,600 NPs registered in the province, and they are already able to diagnose, order and interpret diagnostic tests, and prescribe medications – but not everything their patients need. Since the 2012 federal legislative changes, RNAO has advocated for regulatory amendments to Ontario’s Nursing Act, 1991. Yet nearly four years later, Ontario has fallen behind. “The lack of progress in Ontario is alarming. There is an urgent need to accelerate provincial regulatory changes,” RNAO CEO Doris Grinspun wrote in a letter to Ontario’s Health Minister Eric Hoskins.
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Recently, Hoskins directed the College of Nurses of Ontario (CNO) to develop new NP practice standards that include prescribing controlled substances by March 2017. Asked why Ontario has been slow to move forward, Health Ministry spokesperson David Jensen said prescribing controlled substances is a significant responsibility. “The ministry will need to ensure that the public is protected and that providers are competent to provide this service.” Recently, and in response to RNAO’s pressure, ministry officials have indicated the government plans to enable NPs to prescribe controlled drugs. Free says he doesn’t know why it’s taking so long, but he suspects it’s partly because of concerns around the province’s rising rates of opioid addiction. Ontario has seen a 72 per cent increase in the number of hospital visits for opioid overdose in the past decade, and some experts say the problem is largely due to overprescribing. One study published in Canadian Family Physician found Ontario dispensed oxycodone and fentanyl at the highest rates in the country. But Free says any concerns that having more prescribers would lead to more opioids being prescribed are misguided. There is no evidence to suggest NPs will prescribe any more than physicians do. “Has there been any substantial rises (in opioid prescription) in the last four years in the provinces and territories where NPs are prescribing controlled substances? No,” he says. NP Jason Sawyer says he and his colleagues may even be able to curb the use of opioids. He specializes in acute pain services at Sunnybrook Health Sciences Centre, where he encounters patients taking controlled substances every day. While he can’t prescribe himself, he says he is lucky to work with physicians who trust his assessments, allowing him to provide patients with the right amount of pain medication – which is often less than they were on when they came into hospital. He recently worked with a 42-year-old woman who spent much of the last two decades on opioids. After nearly 40 surgeries for various chronic ailments, she was taking 300 mg of hydromorphone per day via a subcutaneous infusion pump. Sawyer built a rapport with the woman, and together they determined she may not need all the medication she was on. Through a slow weaning process, Sawyer helped her get off opioids completely without any withdrawal symptoms. “Prescribing is not just about giving people more opioids. In many cases, it’s about giving them less,” he says. “If NPs can prescribe opioids...maybe our greatest impact (will be) not creating the next generation of addicts.” Sawyer has worked in pain management for 15 years, and is on the board of directors for the American Society for Pain Management Nursing. He sees the expansion of NP scope in Ontario as an opportunity to reduce the sometimes two-year backlog of patients seeking chronic pain services
in the province. “What would it be like if there were 2,600 more people who had the autonomy and accountability to manage their pain?” he asks. While much of the discussion around controlled substances focuses on pain management and palliative care, an expanded scope would free up NP Erin Ziegler to help a different population. She works at Brampton’s Wise Elephant Family Health Team (FHT), which is one of the only clinics in the Central West LHIN accepting patients to do work-up and assessment for transgender hormones. Of the 40 or so transgender patients on the FHT’s roster, more than half are transgender males either taking testosterone as part of transitional hormone therapy, or planning to start. As an NP, Ziegler performs hormone readiness assessments and monitors blood work for patients on testosterone. But when it comes time to prescribe testosterone or adjust dosage, she must wait to consult with a physician, because testosterone is a controlled substance. Transgender people have historically had a difficult time finding primary care providers who understand trans issues, and are sometimes turned down by physicians. A number of NPs have stepped up to fill the void, but are hindered by their inability to prescribe testosterone. “(Transgender people) are at a very vulnerable time when they’re making the decision to transition,” Ziegler says. “They’re at risk for depression and all the things that go along with (that).” Ziegler has worked with patients who, when they had trouble accessing testosterone through a healthcare provider in the past, resorted to buying it over the internet and administering it themselves. She recalls one patient who used to order testosterone from Asia and pick it up in the U.S., thus becoming a criminal when he brought the controlled substance back over the border. “It broke my heart that’s what he had to resort to just to get medical care in Canada,” she says. And if patients coming to Ziegler’s urban FHT can run into roadblocks accessing testosterone, then she says transgender patients in rural and remote areas of the province – where physicians are not always available – would run into a “dead end.” Free says the same is true for palliative patients outside of urban areas, and that flies in the face of the government’s stated commitment to improve access. “By preventing NPs from prescribing (controlled substances), they’re preventing access to service,” Free says. And by limiting NPs’ scope, they risk alienating these H highly trained professionals. ■ Daniel Punch is staff writer for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. This article was originally published in the September/October 2016 issue of Registered Nurse Journal, the bi-monthly publication of the Registered Nurses’ Association of Ontario (RNAO). www.hospitalnews.com
YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY
Hardwiring accreditation for high reliability By Mike Heenan
ost of us who work in hospitals know the feeling you get when you’re reminded the next scheduled Accreditation Survey is just around the corner, and you’re not quite sure how truly ready your organization is to meet the standards and achieve Exemplary Standing. That looming survey can create feelings of uncertainty, anxiety and even panic among senior leaders, quality staff and frontline providers. Hospital leaders often set off a surge of activity designed to make sure we not only meet the standards but achieve the highest award. Our “Accreditation” activities include staff surveys using the self-assessment questionnaire, meetings for leaders to assess their programs’ compliance to Required Organizational Practices (ROPs), new staff training forums, and the sudden renewal of numerous new policies, procedures and clinical practice guidelines. It’s a lot of work and stress in a complex health environment that’s already at capacity. So why do we react like this? Why do we do this to our physicians, staff and volunteers every four years like clockwork? Perhaps it’s because we treat Accreditation like an event, and not a process. An event is defined as “something that happens – especially something important or noteworthy.” A process is “a series of actions that produce something or lead to a particular result” or “a series of changes that happen naturally.” At St. Joseph’s Health Centre, Toronto we are beginning a journey aimed at transforming Accreditation into a process – a series of planned actions that lead to the results we want and, over time, start to happen naturally. To do this we are reviewing our organization’s plans, policies, procedures and practices to identify exactly where they line up with the principles and standards of Accreditation Canada. We’re looking for ways to achieve Accreditation while simultaneously doing what we need and want to do as an organization. It turns out there are plenty of opportunities. The first thing we are doing is being clear that the founding principles of Accreditation are the same as those of our organization. Both Accreditation Canada and St. Joe’s share a mission to deliver safe, high quality care to our patients every day. As a result we are seeing Accreditation Canada as a true partner in care instead of an organization that audits us every four years. Second, we are incorporating Accreditation into our leadership and quality management frameworks. St. Joe’s is working with Studer Group Canada and has deployed many of the Must Haves® that are part of Studer Group’s Evidence-Based Leadership framework. We are linking the Accreditation Standards and ROPs to tools and tactics such Rounding for Outcomes, Stop Light Reports, Leadership Evaluation Manager®, 90 Day Planning and Goal Setting, and even using Key Words at Key Times to build a culture that supports Accreditation and the mission it sets out for us all. We are also adopting a regular review of policies and procedures and building a new corporate learning model that constantly evolves to meet new standards. Our Board’s www.hospitalnews.com
Quality Committee plays an important role as it requires senior leaders to report annually on how we approach Accreditation – not just in the last year of the cycle. The third part of our approach to embedding Accreditation as a process focuses on our new Integrated Risk Management (IRM) framework, launched in 2015. Senior leaders use the IRM framework to report to the Board quarterly on emerging risks in areas such as strategy, patient care, resources and compliance. We also assess a specific area of our organization each quarter using the relevant Accreditation Standards and ROPs. In the last three quarters
we examined performance and risks in human resources, privacy, and medical affairs. Reviewing our Accreditation compliance routinely allows us to continually identify opportunities to improve. In short, changing Accreditation from an event to a process means integrating the standards and ROPs into all operations – from strategic planning to daily routines. Of course all of this doesn’t happen overnight, and each organization’s journey is unique. But as Quint Studer stresses in his book Hardwiring Excellence, improving quality and safety cannot be seen as an event. This must be grounded in our mis-
sion, vision and values and be lived every day from the top of the organization to the point of care. St. Joe’s leaders, physicians, staff and volunteers are dedicated to advancing the health of our community and delivering high quality care. Like all of us in healthcare, we know it’s a journey that’s never complete. But it is a journey that can be enhanced by embedding Accreditation H into what we do each and every day. ■ Mike Heenan is Vice President, Strategy Communications and Organizational Effectiveness at St. Joseph’s Health Centre, Toronto.
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YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY
pharmacy services By Catalina Guran hrough a two and a half year transformation journey of its pharmacy services, Mackenzie Health is enabling healthcare providers to provide more hands-on care, and help provide excellent quality care to every patient, every time. The multitiered transformation of its pharmacy services has also allowed the organization to better adapt to the changing healthcare landscape and create capacity to efficiently support the significant growth within its community. The endeavour included several distinct projects such as the redesign of medication reconciliation and distribution processes, the expansion of centralized IV admixture and anti-microbial stewardship services, the redesign of the pharmacist and pharmacy technician roles, as well as several other initiatives, each aiming to improve the existing processes. Each of the initiatives delivered on clear outcomes articulated through an engaged process and a robust governance structure supported by meaningful input from key stakeholders, including patient and family advisors.
Essex County Warden, Tom Bain, Windsor Tecumesh MPP, Percy Hatfield, Windsor Mayor, Drew Dilkens and Essex MPP, Taras Natyshak united in support for the new Windsor-Essex Hospitals System.
A region united in an effort to transform
hospital healthcare delivery
By Allison Johnson
hen you head down Highway 401 toward Canada’s southern most region, there’s a buzz that becomes increasingly more apparent as you approach Windsor-Essex. It’s a growing number of people saying in unison, “We Are Ready”. It’s not just a hashtag used to promote the area’s vision for a redesigned, integrated, world-class hospital system, it’s an energy that is percolating in residents eager to turn this vision into a reality. In 2012, Ontario’s then Finance Minister Dwight Duncan, created a taskforce to examine the need and appetite for a new regional acute care hospital that would replace the two current, outdated acute care hospitals. After six months of investigation and extensive community engagement, the taskforce recommended moving forward immediately with the planning. Four years later, they not only have a bold and innovative vision to transform healthcare in the region, including a new state-of-the-art hospital, they also have the $200-million local share committed and started to be raised by way of a joint City and County levy to cover the cost of the build. “I’ve been in this region since I was born. In nearly 50 years, there has not been a project that has united residents like this has,” says Windsor Regional Hospital President and CEO David Musyj,
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who Co-chairs the Steering Committee overseeing the project. “It has brought the city and county closer together, we have elected leaders of all political stripes supporting the project, our local MPPs have been extraordinary, our clinical leadership and medical students have made it clear about the need and there have been numerous community groups and associations including business and labour groups on board. Everyone recognizes this is a once-in-a-lifetime opportunity to improve this system for future generations.”
The plan provides patient’s greater access, connects them to community care, provides more coordinated information to patients for their decision making process and protects the patients. Windsor Regional Hospital is Ontario’s third largest community teaching hospital and eleventh largest hospital. The proposed vision includes replacing its two aging acute care campuses with a singlesite, state-of-the-art hospital. Like the new hospitals that have recently opened in Toronto, Oakville and St. Catherines, this facility will have 80 per cent single- patient rooms to reduce the spread of infection, increase patient privacy and patient flow and modern technology to improve communication and the overall patient experience. In addition, the plan includes a major overhaul of the way mental health is delivered in the region, with the creation of a Centre of Mental Health Excellence to provide a single point of entry for patients of all ages into the mental heath system. It includes an Urgent Care Centre, with the physical “wrap around” presence of primary care providers like the Windsor Family Health Team in the same facility, chronic pain management, dialysis and mental health services for patients in the city’s core. The plan provides patient’s greater access, connects them to community care, provides more coordinated information to
patients for their decision making process and protects the patients. Bottom line the plan as proposed puts Patient’s First. If approved, the province of Ontario will cover 90 per cent of the $2B investment. Residents in Windsor- Essex are already putting money aside to pay the remaining $200 million local share. The municipal levy passed overwhelmingly – by a unanimous vote at County Council, and a 9-1 vote at Windsor City Council earlier this year. What has separated this project from others is the level of community engagement. There have been 50+ community meeting events, opportunities to provide feedback online and during radio phone in programs. In addition, members of the public were invited to provide feedback on criteria used to select the location for a new hospital and apply for a seat on the committee that made the ultimate decision. A volunteer committee made up of region’s residents along with the needed planning expertise ended up selecting the site for the new acute care hospital. Those involved in the project say this level of community participation in a project this size is both brave and unprecedented. “In no community that I know of, anywhere in Canada, has there been such an extensive community engagement process,” says Lucy Brun, a partner at Agnew Peckham with 32 years experience in healthcare planning. Brun says community engagement and collaboration of community leaders allowed this region to move easily through what is often the most challenging part of planning – paying for it. The Steering Committee overseeing this system transformation has completed the first of a 5- stage planning process and submitted it to the community to the Ministry of Health and Long-Term Care and is currently waiting for approval to move onto the functional planning and design. Expect big things once they get the go ahead to implement this system transformation. The residents in Windsor-Essex are ready to modernize the hospitals system H for patients in the region. #WEareready. ■ Allison Johnson is Communications Manager, Windsor Regional Hospital.
Through a two and a half year transformation journey of its pharmacy services, Mackenzie Health is enabling healthcare providers to provide more hands-on care, to help provide excellent quality care to every patient, every time. The journey began when Mackenzie Health started exploring the automation of pharmacy services throughout the organization to enhance patient safety. Following the implementation of automated dispensing units (ADUs) in the Emergency Department and the Intensive Care Unit in 2012, Mackenzie Health identified the need to further review the medication distribution model in order to optimize patients’ access to their healthcare providers. The first significant change was evolving to a 24/7 medication distribution model. Stemmed from process improvement methodology and LEAN events, the new model showed a 23 per cent decrease in the time nurses needed to prepare medication and eliminated the night medication cupboard. The new medication distribution model introduced ADUs in every patient care area of the organization and allowed for enhanced control of narcotic and controlled medications. The implementation of Central Pharmacy Automation and barcoding of all pharmacy inventory, set the foundation for a closed-loop medication system, an essential part of Mackenzie Health’s Smart Hospital Vision at both the existing Mackenzie Richmond Hill Hospital and the future Mackenzie Vaughan Hospital. Continued on page 19 www.hospitalnews.com
YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY Continued from page 18 This significant patient safety investment brought two new automated oral solid packagers and two MedCarousels® – vertical storage and dispensing systems that automate the medication management process, from order fulfillment to automated cabinet replenishment, to patient medication dispensing to restocking. The project also includes the introduction of 14 automated Anaesthesia-RxTM carts to the Operating Rooms and to the Minor Surgery and Endoscopy areas. The automation allowed the Pharmacy department to barcode 100 per cent of the inventory in preparation for the pending implementation of a new electronic medical record that will bring Mackenzie Health to EMRAM level 7 and barcode medication administration. Mackenzie Health also expanded the centralized IV admixture (CIVA) service to provide ready-made doses of IV medications to nurses, resulting in a 66 per cent decrease in the time spent by nurses on this task. Mixed by certified pharmacy staff in a sterile environment, the pre-prepared IVs also contribute to enhanced safety for patients. Nordia Carty, Registered Nurse at Mackenzie Health acknowledges that “CIVA allows for safer medication administration. It reduces time for reconstitution and drug calculation. It is also more efficient and overall improves time for nursing.” With the regulation of Pharmacy Technicians through the Ontario College of Pharmacists during the same period, the two-year transformation lent itself to a redesign of the roles of the pharmacy
Mackenzie Health’s Pharmacy Transformation Team. technicians and pharmacists at Mackenzie Health. Optimizing the technicians’ roles in medication distribution and documentation of best possible medication histories allowed 3.4 hours per pharmacist per day to be redistributed to direct patient care activities, enhancing the clinical role of the pharmacists. This included the introduction of medical directives to delegate prescribing of certain antibiotics that required therapeutic drug monitoring. Pharmacists were also trained and certified to provide basic antimicrobial stewardship in all patient care areas of the hospital. The Pharmacy Transformation further contributed to patient safety at Mackenzie Health through the redesign of the medi-
cation reconciliation process throughout the patients’ hospital journey. Pharmacy technicians were trained to take the best possible medication history from patients to facilitate medication reconciliation at the time that admission orders are being written by physicians. “Giving pharmacy technicians the opportunity to complete Medication Reconciliation at Admission has allowed us to work within our expanded scope and provide physicians with a comprehensive list of patients’ medications, making us an integral part of the care team and ensuring our patients are safe,” says Nisha Groodoyal, Registered Pharmacy Technician at Mackenzie Health. Pharmacists are also working col-
laboratively with the healthcare team at discharge to ensure patients are informed about changes to their medications as they transition out of hospital. Mackenzie Health is committed to relentlessly improve care to create healthier communities and the Pharmacy Transformation journey is an example of improving patient safety, enhancing operational efficiency and delivering value to patients by maintaining momentum, adaptability in approach and change management H techniques. ■ Catalina Guran is a Communications and Public Affairs Consultant at Mackenzie Health.
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INSIDE From the CEO’s desk ......................... 10 Nursing Pulse ..................................... 14 Legal Update ......................................15 Evidence Matters ...............................20 Safe Medication .................................22 Careers ...............................................23
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DECEMBER 2016 HOSPITAL NEWS
YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY
Breaking the cycle of crowded hospitals By Rob MacIsaac
he Ontario government recently re-introduced the province’s health system restructuring legislation, the Patients First Act, now known as Bill 41. The Bill, once enacted, will be an important enabler for us in Hamilton to change the way our healthcare is coordinated and delivered. In so doing, we have a chance to deliver better care for people in our community while also creating a more sustainable healthcare system. Why is change needed? For starters, we are using our hospitals too much and for too many things. That’s not surprising. Everyone knows where the hospital is, we never close, and we don’t turn anyone away. As a result, we have become the provider of a very broad range of health care and social services. If you have multiple, chronic health conditions, if you are living in poverty, or if you often need health services after hours, there is a good chance you’ll turn to a hospital for service on a regular basis. Some people visit the Emergency Departments at Hamilton Health Sciences multiple times each week. This might seem like an abuse of the service, but these people really do need help – they are often in genuine crisis. To the credit of our frontline workers, hospitals respond with compassion. We assess people on the spot, provide them
medical attention, admit them to a bed when necessary, help them through their crisis, and send them home. But then they come back and the cycle repeats itself. What if we could instead help break the cycle by working collaboratively with social services and other health service providers in the community? What if we began proactively intervening to help people better manage their health to reduce the chance they will need hospital care?
Population health addresses the reality that our community’s health is profoundly affected by factors far removed from the medical care offered by a hospital. This concept is called population health. It addresses the reality that our community’s health is profoundly affected by factors far removed from the medical care offered by a hospital. Housing, income, education, and family support are all significant determinants of how much you will use a hospital. If you don’t have a roof over your head, if you aren’t eating properly, if you don’t have a family member around to catch you when
you fall, you are very likely to become a frequent user of hospital services. At Hamilton Health Sciences, we are using a population health approach to plan the development of our hospital services and the long term redevelopment of our facilities (OurHealthyFuture.ca). This is not a quick or easy fix. But we believe that, over the long-term, a population health approach will make our community healthier and help us better manage the growing demand for hospital services. There’s no universal definition of population health. At Hamilton Health Sciences, it means that we want to get ahead of the demand for hospital services by addressing the numerous factors that put people at risk for hospitalization. This will require our community taking a coordinated approach to providing the broadest range of health services to our community – from disease treatment to prevention, rehabilitation to management, and also health promotion and protection. Two important examples of health conditions that can be better managed using a population health approach are Chronic Heart Failure (CHF) and Chronic Obstructive Pulmonary Disorder (COPD). Together, they are the leading causes of potentially preventable hospitalization in our community. These are progressive health conditions that, when left untreated or mismanaged, can require numerous
and lengthy visits to the hospital. The better response, though, may be teaching someone how to properly use and better manage their medication, or ensuring they have appropriate housing, or simply providing them with access to a friendly voice who understands their challenges and provides good advice. This kind of approach is pretty far from today’s reality. If we are to change this channel, we’ll need to change the way family medicine, home care, first responders, social services and hospitals work with each other. At HHS, we are now actively collaborating with the City of Hamilton to boost supportive housing in our community, because we know that a lack of housing creates an over-reliance on our services. Similarly, we want to work with family doctors, home care and social service providers, as well as public health to find new ways to serve the community together. Sustaining these efforts will mean acknowledging our shared responsibility for providing the best possible care to our community. It will also require an openness from all sides to finding new ways of working together. We’ll know we have succeeded in this effort when our hospitals are H no longer filled beyond their capacity. ■ Rob MacIsaac is President and CEO of Hamilton Health Sciences.
See what Hospital News is working on in 2017 ƌŝŶŐŝŶŐǇŽƵƚŚĞůĂƚĞƐƚŝŶŚĞĂůƚŚĐĂƌĞŶĞǁƐĂŶĚďĞƐƚƉƌĂĐƟƐĞƐ Here are some of our upcoming supplements... January
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YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY
Accreditation success for
Humber River Hospital By Gerard Power
hen Humber River Hospital opened its new facility on October 18, 2015, it dramatically altered how acute care hospital workflows and processes would work in future. As North America’s first fully digital hospital, the implementation of so many state-of-the-art technologies required Humber to reinvent many aspects of the hospital’s operations. One result of this dramatic transformation was that a number of already accredited hospital services had to undergo a ‘re-accreditation’ process after opening, as professional bodies looked to ensure their standards were still being met amidst so much change. In November of 2015 the Ontario College of Pharmacists conducted a compliance inspection of Humber River’s Pharmacy Program. This was a mandated review by the College given the move to our new hospital, and the dramatic changes in pharmacy operations, especially with the introduction of robotic technology. It was done to ensure Humber’s continuing adherence to the criteria contained in all legislation and regulations enacted to ensure a safe medication management system in the Province. The College noted that this took significant effort, coming so soon after moving day. In awarding them successful completion of the assessment, The College of Phar-
macists also congratulated them for their commitment to patient safety and continuous quality improvement. Most notable was the College’s acknowledgement that the Pharmacy team’s cooperation and feedback throughout has led to improvements in the College’s assessment criteria and evaluation processes for pharmacies. Our Laboratory also had to go through a similar process following the move to the new site. Here again the changes in workflows and processes resulting from the introduction of robotic technology required a surveillance assessment by the Institute for Quality Management in Healthcare. The Laboratory team received a full 4-year Accreditation – the best possible result available for them to achieve. As well, the Bariatric Surgery Program at Humber River Hospital was successfully re-accredited by the American College of Surgeons (ACS) as a MBSAQIP Accredited – Comprehensive Center. This designation is a source of pride and speaks to the continued dedication and compassion exemplified by HRH in exceeding standards of the highest quality and the use of best practices for treating the disease of morbid obesity. To be a MBSAQIP Accredited - Comprehensive Center, more than 100 cases must be done per year, while each surgeon must do more than 50 cases per year. The program’s outcomes are closely monitored,
Dr. Laz Klein performs laparoscopic bariatric surgery at Humber River Hospital. following strict protocols and procedures, to deliver results expected from a Bariatric MBSAQIP Accredited – Comprehensive Center. The MBSAQIP Verification Subcommittee Co-Chairs Dr. David Provost and Dr. Daniel Jones, in the official designation letter, noted that “We want to thank you for your support of the MBSAQIP and all that you do to meet the needs of the metabolic and bariatric surgery community. Your program is part of an elite group of MBSAIP-Accredited centres. Once again, congratulations on this achievement.” Having outside professional organizations come in and evaluate our programs
and services is an important reality check in seeing how we are doing because it confirms where we are doing work to a high standard; and, frankly, points to areas where improvement may be possible. Results such as those received by these programs and services highlight the skill and commitment that permeates our organization. The Humber River team is dedicated to high quality healthcare. Providing great care to Humber River’s patients and families is our ultimate goal – that’s what we try H to achieve every day. ■ Gerard Power is Director, Public & Corporate Communications at Humber River Hospital.
DECEMBER 2016 HOSPITAL NEWS
YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY
Product Feature: LifeVac
Educational & Industry Events To list your event, send information to “firstname.lastname@example.org”. We try to list all events and information but due to space constraints and demand, we cannot guarantee it. To promote your event in a larger, customized format please send enquiries to “email@example.com” Q November 27–December 2, 2016 RSNA 2016 McCormick Place, Chicago, United States Website: www.rsna.org Q December 1–2, 2016 The Foundations and Scholarship of Clinical Teaching University of Toronto, Faculty of Nursing Toronto, Ontario Website: www.bloomberg.nursing.utoronto.ca Q December 8–9, 2016 Data Analytics for Healthcare Toronto, Ontario Website: www.strategyinstitute.com Q January 23–April 3, 2017 Advanced Ostomy Care and Management University of Toronto, Faculty of Nursing Toronto, Ontario Website: www.bloomberg.nursing.utoronto.ca Q January 28-29, 2017 NCLEX-RN Exam Prep Course University of Toronto, Faculty of Nursing Toronto, Ontario Website: www.bloomberg.nursing.utoronto.ca Q January 31-February 1, 2017 IoT, Big Data Healthcare Summit Western Canada Vancouver, British Columbia Website: www.iotevents.ca Q February 19-23, 2017 2017 HIMSS Annual Conference & Exhibition Orange Country Convention Centre, Orlando FL Website: www.himssconference.org Q March 1-5, 2017 Canadian Critical Care Conference Whistler, British Columbia Website: www.canadiancriticalcare.ca Q March 8-9, 2017 Mobile Healthcare Holiday Inn Toronto Airport, Toronto Website: www.mobilehealthsummit.ca Q March 21-22, 2017 Industrial Autonomous Vehicles Summit Calgary, Alberta www.iotevents.ca Q April 3-5, 2017 Together We Care Toronto Congress Centre, Toronto Website: www.together-we-care.com Q April 26-27, 2017 Healthy Canada Conference 2017: Access to Affordable Medicines Old Mill, Toronto Website: www.cchl-ccls.ca Q June 4-7, 2017 eHealth Conference & Tradeshow Toronto, Ontario Website: www.ehealthconference.com To see even more healthcare industry events, please visit our website www.hospitalnews.com/events HOSPITAL NEWS DECEMBER 2016
LifeVac: Antichoking device
Submitted by LifeVac
very year thousands of peoplee are saved by the Heimlich maneuver. What people rarely hear about are the many instances in which the Heimlich fails. Too often when this happens, the victim dies. As good as a technique the Heimlich is in emergency situations, it is far from perfect, and many times it has not worked, often resulting in death.
The vision of LifeVac came from a story that Arthur Lih, inventor of LifeVac, heard of a woman in a hospital weeping following the death of her young son. There are also many diseases which make victims more prone to choking or situations where the Heimlich may be difficult to administer; such as with individuals who are pregnant, in wheel chairs, or who have disorders such as Dysphagia, ALS, Asthma, Cerebral Palsy, Febrile Seizure, Huntington’s Disease, Swallowing Difficulties, Stroke, Brain Injury, Multiple Sclerosis Muscular, Dystrophy, Parkinson’s Disease, Esophageal Spasm, Gastroesophageal Reflux Disease (GERD), Esophagitis, Diffuse Spasm, Esophageal Tumors, and Neurological Disorders. Choking is a serious threat, with concerning statistics. • A leading cause of death in children and persons over the age of 65; • 4th leading cause of accidental death in children under 14 years of age; • More people die from choking than from fires or drowning; • Leading cause of brain injury in young children; • 17,000 infants and children are treated in hospital emergency rooms for choking each year. The vision of LifeVac came from a story that Arthur Lih, inventor of LifeVac, heard of a woman in a hospital weeping following
h young you ung son. son It was startling start startl tling the death of her hi g avail to him that there was nothing available that could assist in keeping someone from choking to death. Arthur went on to create LifeVac, a non-powered device that could clear the airway of a choking victim when standard choking protocol has been followed without success. Since the introduction of LifeVac in the US in 2015, the product has been delivered to thousands of homes, Fire, Police, Ambulances, Care homes, Restaurants & Schools. Arthur has worked tirelessly to create awareness of Choking Deaths and introduce LifeVac as a possible life saving device. LifeVac has received significant media attention in the US and has only recently been introduced to Canada, in October 2016. On June 6, 2016 LifeVac saved the life of a female nursing home resident in Dyfed, Wales. The Allt-y-Mynydd Care Home in Dyfed, Wales, purchased a LifeVac after a resident choked to death in January of that year. Two days after receiving their LifeVac, a female resident was choking on her lunch. An attendant used the LifeVac to successfully remove the object and clear the victim’s airway with one pull on the device. “LifeVac was developed with, and has been endorsed by, doctors, EMTs and first responders,” says Lih. “We will continue our efforts to ensure LifeVac is in every school, nursing homes and anywhere a person is at a high risk of choking. LifeVac’s mission is to eliminate these tragic deaths.” LifeVac Canada Inc., based in Mississauga, Ontario, was formed to distribute LifeVac in Canada and provide awareness of choking prevention. LifeVac is a registered Medical Device with Health Canada, CE, and the FDA. LifeVac has also been peered reviewed and published in The American Journal of Emergency Medicine and The American Journal of Gastroenterology. Although a medical device, LifeVac does not require a prescription and is available for H online purchase at https://lifevac.ca/. ■ Submitted by LifeVac. www.hospitalnews.com
Safe Medication 23
Spot the difference: Citalopram vs. esCitalopram
By Kevin Li and Certina Ho
italopram and escitalopram are cornerstone, first-line therapies for depression and are widely used options for anxiety. They are two commonly prescribed selective serotonin reuptake inhibitors (SSRIs) and are amongst the top 30 prescribed medications in 2015. Along with their popular use, citalopram and escitalopram are associated with a myriad of medication incidents that
involve both technical and therapeutic issues, such as a cardiac condition known as QT prolongation. Although there are potential solutions to these preventable incidents, the strong resemblance between this drug pair makes it challenging for them to be detected by any single safeguard. Therefore, a team-based approach among healthcare providers will facilitate multiple layers of preventative measures, promote vigilant
Table 1: Theme #1 Pharmacists & Pharmacy Staff – A Collaborative Effort in Enhancing Medication Safety Subtheme: Strength/Dosage Selection Errors Potential Contributing Factors Team-Based Preventions Historical influences – prescription order entry errors due to copying past prescriptions or being influenced by previous prescription order entries
To prevent confirmation bias, policies may be considered to restrict or limit the process of copying from previous prescriptions (where applicable).
Inattentional blindness – the event in which an individual fails to recognize an error although it has been seen.
Incorporate independent double checks in the pharmacy workflow.
Environmental factors (e.g. workload, distractions in the pharmacy)
Incorporate independent double checks in the pharmacy workflow.
Subtheme: Tablet-Splitting Issues Potential Contributing Factors
Misreading or misinterpretation of prescription order due to illegible handwriting
Verify medication and directions of prescription with the patient and/or the prescriber (whenever applicable).
Complex tapering regimen – antidepressants often require gradual adjustments of dosage when initiating or discontinuing therapy
Write out dosage calculations or use visual tools (e.g. a calendar) to clarify tapering prescription orders. Incorporate independent double checks in the pharmacy workflow.
Subtheme: Look-alike, Sound-alike Drug Names Potential Contributing Factors Team-Based Preventions Lack of differentiation – Citalopram and escitalopram have nearly identical strengths, dosage regimens, indications, names, and similar pharmacological properties
Train and remind front-line pharmacy staff to routinely verify prescribed medications, indications, and directions of use with the patient and/or the prescriber (whenever applicable). Notify or communicate with patients and investigate all changes in therapy. Educate patients of possible look-alike, sound-alike drug pairs (if applicable) and to be watchful of their medications. Incorporate independent double checks in the pharmacy workflow. Discuss and address medication safety issues (e.g. look-alike, sound-alikes drug names and other common technical errors) during staff meetings.
screening, and encourage an overall safety culture. ISMP Canada conducted a multi-incident analysis of medication incidents involving citalopram and escitalopram to identify potential contributing factors that may highlight medication-use processes where effective teamwork can improve patient safety. Medication incidents were retrieved from the ISMP Canada’s Community Pharmacy Incident Reporting (CPhIR) Program from the year of 2015. Two major themes were identified and they were further divided into subthemes as shown in Table 1 and Table 2.
Table 2: Theme #2 Pharmacists & Prescribers – A Team-Based Approach in Embracing Patient Safety Subtheme: Look-alike, Sound-alike Drug Names Potential Contributing Factors Team-Based Preventions An implied culture or habit of communicating drug names with either brand names or generic names only among healthcare providers
Include both brand name and generic name on all prescriptions and all forms of communication.
Illegible hand-written prescriptions or fax prescription orders
Consider arrangements for e-prescribing to eliminate hand-written prescriptions or hand-written forms of communication, such as computerized physician order entry (CPOE) systems. (Note: CPOE systems may introduce other safety challenges in the medication-use process. Therefore, always assess the risks versus benefits when implementing a new system in your practice setting.)
Subtheme: Therapeutic Errors Potential Contributing Factors
Absent or limited ability to detect potential drug-drug interactions within CPOE systems at the point of prescribing
Incorporate CPOE systems with built-in or integrated drug-drug and drug-disease interaction-checking functionality.
Limited familiarity with QT-liable medications among healthcare practitioners, which may lead to an omission to communicate or document potential risks for QT prolongation when providing patient care
Consult a reliable resource, such as Credible Meds (www.crediblemeds.org) whenever initiating medications with QT liability. Notify or communicate with patients regarding potential risks for QT prolongation (if applicable).
Patients may seek episodic care (e.g. walk-in clinics and urgent care centres) or utilize multiple pharmacies for filling their prescriptions, which may lead to incomplete medical/medication information in a patient’s health records at an individual practitioner’s office or at a particular pharmacy
It is important to ensure that a patient’s complete medical/medication record is obtained at the point of care. Incorporate the use of ISMP Canada’s “5 Questions to Ask about your Medications” when engaging your patients in a dialogue (www. ismp-canada.org/medrec/5questions.htm) – this will help capture and communicate changes in patients’ medication therapy.
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Although citalopram’s and escitalopram’s risk for harm is typically mild in nature, medication incidents still have potential repercussions should an error occur in the vulnerable patient groups (e.g. patients with high risk for QT prolongation). As a result, caution should be exercised in all stages of the medication-use process and considerations to implement effective team-based preventions and practices as outlined in H Table 1 and Table 2 should be made. ■ Kevin Li is an Analyst at the Institute for Safe Medication Practices Canada (ISMP Canada) and Certina Ho is a Project Lead at ISMP Canada.
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DECEMBER 2016 HOSPITAL NEWS
HOSPITAL NEWS DECEMBER 2016
YEAR IN REVIEW/FUTURE OF HEALTHCARE/ACCREDITATION/PHARMACOLOGY
Focus: Year in Review, Future of Healthcare, Accreditation and Pharmacology