Hospital News March 2021

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Inside: From the CEO’s Desk | Evidence Matters | Safe Medication | Special Focus: Infection Control

March 2021 Edition


Inside Sunnybrook’s

pandemic response Page 10

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They say respect has to be earned. When nurses are called upon…we answer the call. When patients need our care…we’re there for them. When every day brings increasing risk...we hold the line. The government often calls us heroes. But what we really need from them is action. Make sure we have the right PPE in our workplaces. When we’re exposed to COVID-19 and have to self-isolate, pay us. Give us a say in our scheduling and working conditions. Don’t override our collective agreements. Ensure that our compensation is determined fairly. To Ontario’s Conservative government we say this: Prove through your actions that you respect our courage and value the vital work we’re doing.


Contents March 2021 Edition


Ornge displays skill and flexibility


▲ Cover story: Inside Sunnybrook’s pandemic response


▲ Mobilizing a green-friendly organization


▲ Minimally invasive mitral valve repair ring

COLUMNS Guest editorial .................4


In brief ..............................6 From the CEO’s desk .....16 Special focus: Infection control ............21 Ethics .............................46 Long-term care ...............48 Safe medication .............52 Evidence Matters ...........53

▲ Special focus: Infection control


Mobile Vaccine Team helps inoculate the vulnerable


▲ Light kills SARS-CoV-2


Vaccination, trust in science and patience is the only way out of this pandemic By Linda Silas COVID-free future is within our reach – a future where it’s safe to hug again and where our smiles no longer need to be hidden behind a mask. To get there, we will need a robust vaccination drive. We will need Canadians to roll up their sleeves and get vaccinated. But we will also need to be patient. Immunizing the country won’t happen overnight. It will be an incremental process informed by science and one that seeks to immediately stem the loss of life. Earlier this month, the Canadian Federation of Nurses Unions encouraged all health care workers, all essential workers and the general public to receive the vaccine when they become eligible. We also urged governments across Canada to speed up the rollout of the vaccine, especially to those most likely to experience severe illness, such as seniors, Indigenous people and racialized people – all of whom have been shown to be most at risk of infection. Nurses have also signaled that they are ready and willing to step up and help the government with the vaccine rollout by joining health care teams at vaccination clinics across Canada. While the news of some delays in delivery of the Pfizer vaccine may give us pause, governments must strive to speed up the immunization and rapidly increase the number of clinics where the vaccine is available. This is how we will contain this virus and counter its spread. What’s also been lacking in Canada’s vaccine delivery program is evidence-based information. Within this vacuum, misinformation, vaccine myths and mistrust have thrived. Sadly, many Canadians are hesitant to get vaccinated, particularly among marginalized communities who, we recognize, have all too often experienced negative interactions with the medical community. As nurses, we believe that any risk posed by the vaccine is far outweighed by the benefits in being protected from COVID-19.


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As with any other medical treatment, informed consent is required. It’s our job, as health professionals, to provide facts – and yes, empathy – when patients express concerns about being vaccinated. Everyone who gets the vaccine must understand the benefits of immunization, as well as any potential risks. All Canadians should be empowered to make an informed decision. Some individuals have expressed concerns about the record turnaround time for these vaccines. Producing multiple vaccines in less than a year was the result of a momentousw global effort, harnessing the ingenuity of a scientific community united in a common objective. Large-scale trials on the efficacy of vaccines involved tens of thousands of participants, including many from diverse backgrounds. The trials resulted in high rates of protection with few or no reported serious adverse events. Despite the compressed timelines, no shortcuts were taken: the same standards were applied to these vaccines as for any other vaccines that have been developed. In Canada, we know the approval process by Health Canada is safe and effective; their assessment of scientific and clinical evidence is done independently and is known to be stringent. We also know that historically, immunization programs have saved countless lives worldwide. The COVID-19 vaccines approved thus far have the potential to provide much-needed protection against the continued spread of the SARS-CoV-2 virus but this will only happen if sufficient numbers choose to be vaccinated. As Canada’s nurses, we want to encourage all those living in Canada to receive the vaccine as soon as they are able. Together, we can contain this virus, end the pandemic and take part in Canada’s post-pandemic H recovery. ■

Linda Silas is a nurse and President of the Canadian Federation of Nurses Unions, representing nearly 200,000 nurses and student nurses across the country.

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World first: Minimally invasive mitral valve repair ring offers option for inoperable patients By Katherine Nazimek n a first-in-human procedure, a team of cardiologists and cardiac surgeons at Sunnybrook Health Sciences Centre implanted a specialized mitral valve repair ring through a catheter, giving hope to patients who otherwise would be out of treatment options. Mitral regurgitation is a common heart disease as people age. When the valve no longer closes properly, blood flows backwards into the upper heart chamber and patients find themselves out of breath during normal activities. If left untreated, severe mitral regurgitation can cause heart failure and serious heart rhythm problems or arrhythmias. Open heart surgery has been the standard treatment for mitral regurgitation and involves stopping the heart and keeping it pumping on a machine. For patients who are older or have other medical complications, the surgery can be risky and has a recovery time of one to three months. A minimally invasive procedure using a MitraClip is an option for patients with severe symptoms who may be too at risk for openheart surgery, but not everyone is a candidate. “There are only one or two devices worldwide that do this type of mitral valve repair minimally invasively, and none are readily available in North America,” says Dr. Andrew


Photo credit: Kevin Van Paassen/Sunnybrook Health Sciences Centre

From left: Dr. Eric Cohen, interventional cardiologist; Dr. Gideon Cohen, cardiac surgeon and head of cardiac surgery; Dr. Andrew Czarnecki, interventional cardiologist and medical director of the transcatheter mitral valve program at Sunnybrook’s Schulich Heart Centre perform a catheterbased mitral valve repair procedure Czarnecki, an interventional cardiologist who performed the procedure with Dr. Eric Cohen, interventional cardiologist and Dr. Gideon Cohen, cardiac surgeon of Sunnybrook’s Schulich Heart Program. “The only approved device available is the MitraClip, but based on anatom-

ic challenges, the patient was not a candidate.” The ability to use various medical devices to repair valves, such as the MitraClip and TAVI depend on a variety of factors, but most notably they need to fit the anatomy of the patient’s heart.

The AMEND™ annuplasty ring can be used for inoperable or highrisk surgical patients to provide treatment for acute mitral regurgitation. During the procedure, a catheter is inserted into the patient’s groin and travels up into the mitral valve. The ring is fed through this catheter, where it finally grasps and tightens around the valve, effectively preventing blood from leaking. The ring remains in place while the catheter is removed, with the entire procedure taking approximately two hours, and is performed under general anesthesia without the use of a heart-lung machine, and without opening the chest. “While the ring alone may be enough for some patients, it also adjusts the anatomy of the valve to allow for a more conventional MitraClip repair that would otherwise be infeasible,” says Dr. Eric Cohen. “This unique technology provides us yet another important tool with which to treat patients previously deemed inoperable,” adds Dr. Gideon Cohen. “We are pleased to have been able to offer this procedure to a patient who had no other surgical or device options.” The AMEND device is limited to investigational use and is not commercially available. It was performed at Sunnybrook with permission from the Health Canada Special Access H Program. ■

Katherine Nazimek is a communications advisor at Sunnybrook Health Sciences Centre.



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Risk of death

from COVID-19 3.5 times higher than from flu new study published in CMAJ (Canadian Medical Association Journal) found that the risk of death from COVID-19 was 3.5 times higher than from influenza. “We can now say definitively that COVID-19 is much more severe than seasonal influenza,” says Dr. Amol Verma, St. Michael’s Hospital, Unity Health Toronto, and the University of Toronto. “Patients admitted to hospital in Ontario with COVID-19 had a 3.5 times greater risk of death, 1.5 times greater use of the ICU, and 1.5 times longer hospital stays than patients admitted with influenza.” These findings are similar to study results recently reported in France and the United States. The study compared hospitalizations for influenza between November 1, 2019, and June 30, 2020, in seven large hospitals in Toronto and Mississauga – areas with large populations and high levels of COVID-19. It included all pa-


PATIENTS ADMITTED TO HOSPITAL WITH COVID-19 HAD 1.5 TIMES GREATER USE OF THE ICU tients admitted to medical services or the intensive care unit (ICU) for influenza or COVID-19. There were 783 hospitalizations for influenza in 763 unique patients compared with 1027 hospitalizations for COVID-19 in 972 unique patients (representing 23.5 per cent of all hospitalizations for COVID-19 in Ontario during the study period). Most patients hospitalized with COVID-19 had few other illnesses, and 21 per cent were younger than 50 years of age. People younger than 50 also accounted for almost one-in-four (24 per cent) admissions to the ICU. “Many people believe that COVID-19 mainly affects older

people,” says Dr. Verma. “It is true that COVID-19 affects older adults most severely. We found that among adults over 75 years who were hospitalized with COVID-19, nearly 40 per cent died in hospital. But it can also cause very serious illness in younger adults. Adults under 50 accounted for 20 per cent of all COVID-19 hospitalizations in the first wave of the pandemic. Nearly one-in-three adults younger than 50 hospitalized with COVID-19 required intensive care, and nearly one in 10 required an unplanned readmission to hospital after discharge.” People hospitalized for COVID-19 had greater use of the ICU, were more likely to be put on a ventilator and had longer hospital stays than people with influenza. “Characteristics and outcomes of hospital admissions for COVID-19 and influenza in the Toronto area” H was published February 10, 2021. ■

New drugs entering Canada at steady rate over past 5 years he latest edition of the Patented Medicine Prices Review Board (PMPRB) Meds Entry Watch reports that 40 new-to-Canada medicines were approved for market in 2018, of which 22 had reported sales by the end of 2019. This is in line with the annual rate of approximately nine new approvals per quarter since 2015, a trend that continued steadily into 2019. Internationally, 51 new drugs were first approved in the US, Europe, and Canada in 2018, of which more than two thirds were high-cost and over 60% were treatments for rare diseases. Four of the five top-selling new medicines were approved in Canada in the



same year, including the antiviral drug bictegravir (Biktarvy), which alone accounted for over half of total sales for the 51 new medicines by the end of 2019.


• In 2018, Health Canada approved 40 new-to-Canada medicines, of which 22 had reported sales by Q42019, accounting for 1.6% of the total Canadian pharmaceutical market. On average, international prices for these medicines were 19% lower than the prices paid by Canadians. • 51 new medicines were approved internationally in 2018, of which over 60% had an orphan designa-

tion from the FDA and/or the EMA while more than 30% were indicated for the treatment of cancer. • Health Canada had approved 20 of the 51 new medicines by the end of 2019, of which nine had recorded sales in Canada, placing Canada ninth in the OECD and in line with the PMPRB11 comparator countries, most of which have lower average patented medicine prices. • 47 new medicines received market authorization in 2019, of which 16 were approved in Canada by Q32020. In total, 40% (19) of the 2019 new medicines were orphan-designated while just under a quarter H were oncology treatments. ■

Study finds increased chronic disease complexity among Ontario patients over 10 years new analysis of diagnostic data in Ontario found increases in patient complexity and chronic disease. It is published in CMAJ (Canadian Medical Association Journal) Using the Canadian Institute for Health Information’s (CIHI) Population Grouping Methodology, the researchers estimated patient complexity by looking at diagnostic codes from all available health care settings from 2008/09 to 2017/18, which allowed for a detailed understanding of chronic illness in Ontario. “The resources required to treat Ontario’s patients have increased over the 10-year period beyond what could be expected from population aging,” says Dr. Sharada Weir, Healthcare Evaluative Research Director with the Economics, Policy & Research Department, Ontario Medical Association, Toronto, Ontario. The authors took advantage of the rich clinical information provided by the CIHI diagnostic grouping tool to estimate the prevalence of 85 chronic diseases and the co-occurrence of two or more diseases (multimorbidity). “While the overall increase in the number of patients with chronic disease is largely because of an ageing population, the increase in chronic disease prevalence for adolescents and young adults may signal future health risks for this cohort,” says lead author Mitch Steffler, Data Scientist with the Economics, Policy & Research Department, Ontario Medical Association, Toronto, Ontario. “These trends in chronic illness and patient complexity have implications for health system planning. It is important to ensure that health system resources can meet the needs of an increasingly complex patient population.” “Trends in prevalence of chronic disease and multimorbidity in Ontario, Canada” was published February 22, H 2021. ■



Ornge displays skill and flexibility in responding to COVID-19 in Ontario By Grant Scollay rnge operates critical care ambulances, airplanes and helicopters that are mobile intensive care units (ICU). Like all ICUs in Ontario, we are facing new and significant challenges during this COVID-19 pandemic. Ornge has been forced to adapt to these unique challenges – the most significant being the uncertainty, the acuity and the volume of patients. For Ornge, like all frontline services, early 2020 was fraught with uncertainty. What would our role be in fighting this pandemic? How would we as an organization cope with industry wide PPE shortages, red-lining hospital capacity and surging patient numbers? Nearly a year later, our role is clear and focused. The surge of seriously ill COVID-19 patients in Ontario continues to push health care resources to the extreme. One of the most important tools has been bed equalization, or load balancing. In partnership with CritiCall Ontario, Ornge coordinates the dispatching of COVID-19 transports from hospitals across the Greater Toronto Area (GTA) to balance ICU capacity across the region, preventing the system from becoming overloaded. Stable patients who can be transported with Advanced or Primary Care paramedics are dispatched to local Paramedic Services. For patients who require Critical Care or ICU level support, Ornge’s fleet of ambulances, specifically within the GTA, have been utilized heavily as part of the ‘decanting’ process. More recently, Ornge deployed its newly formed Surge Response Team (SRT). The SRT played a pivotal role ensuring ICU patients were safely and efficiently transported from Mackenzie Health in Richmond Hill to the new Cortellucci Vaughan Hospital. In just over nine hours, this highly coordinated effort between hospital resources, York Region Paramedic Services and Ornge saw 12 ICU patients transport-


The Surge Response Team.

IN PARTNERSHIP WITH CRITICALL ONTARIO, ORNGE COORDINATES THE DISPATCHING OF COVID-19 TRANSPORTS FROM HOSPITALS ACROSS THE GREATER TORONTO AREA (GTA) TO BALANCE ICU CAPACITY ACROSS THE REGION, PREVENTING THE SYSTEM FROM BECOMING OVERLOADED. ed. This joint operation serves as another example of how Ornge critical care resources continue to support our healthcare partners in addressing the capacity concerns in our hospitals. Early in the pandemic, it became clear that Extracorporeal Membrane Oxygenation (ECMO) would be an important tool for managing the most severely ill COVID-19 patients. As a result, University Health Network Toronto General became a frequent destination of the critical care ambulances in the GTA. Critical care ambulances from Ornge, and the Critical Care Transport Unit at Toronto Paramedic Service (a partnership with Ornge), saw a significant increase in patients going for ECMO consideration. These patients are often being transported because traditional therapies offered by community or regional hospitals were not effective. Ornge paramedics face the daunting task of continuing to provide this high level of care, in far less space and with fewer human resources.

Other COVID-19 challenges needed to be addressed with ingenuity. First, questions regarding the spread of droplets within aircraft could not be answered, requiring research to be conducted within our unique environment; research that has been completed and is pending publication. As well, Ornge addressed issues related to providing PPE to paramedics for operations in the extremes of weather common in Ontario’s North. Finally, COVID-19 has also seen a demand to have patients transported in the prone position. While proning patients improves oxygenation, it poses many challenges in transport, requiring changes in both process and equipment to ensure patient safety as equipment used during transport was not designed to be used with patients laying on their stomachs. Ornge has been flexible in its response to the needs of hospital partners, redeploying and adding capacity within its land ambulance fleet around the GTA and Ontar-

io. A temporary Critical Care Land Ambulance has been based in Chatham-Kent, and other units redeployed daily first to Hamilton (in 2020), and then Oakville beginning in early April of 2020. An additional critical care ambulance will be added to Ornge’s online fleet on a temporary basis, based in Mississauga, to continue to aid with patient transports and any potential surges being forecasted in the coming weeks and months. This was challenging as Ornge is simultaneously leading the vaccination efforts of 31 remote Indigenous communities, a multi-organization effort known as Operation Remote Immunity. Even as we share staffing resources with Operation Remote Immunity and continue to add critical land ambulance capacity to our operation, Ornge Paramedics continue to put up their hand to volunteer to assist, recognizing the importance of the moment. Uncertainty regarding COVID-19 remains; new variants are on the horizon and the next challenges are unknown. Ornge will continue to meet new challenges head-on. As COVID-19 increases the acuity and the demands on critical care within the province, Ornge has evolved to meet the high expectations placed on them by our patients, as well as remaining a trusted partner with H Ontario’s hospitals. ■

Grant Scollay is a Paramedic for Ornge’s Critical Care Land Ambulance program. 8 HOSPITAL NEWS MARCH 2021





Inside Sunnybrook’s

pandemic response: A photo essay hen Canada’s first case of the novel coronavirus, COVID-19, was confirmed in a patient at Sunnybrook on January 25, 2020, the hospital was preparing for a potential pandemic. In the past year, Sunnybrook’s teams have worked tirelessly through stress, fear, uncertainty and a fundamental shift in the way health care is delivered. To recognize the strength and resiliency of our staff, physicians, researchers, students, volunteers, and patients and their loved ones, these photos offer just a brief glimpse into the hospital since January 2020. H View the full gallery at ■


Left: January 23, 2020 had already been a busy day in the Emergency Department at Sunnybrook. The team, including registered nurses Natacha Hainzelin and Shauna Tavernier, received a heads-up from paramedics that a patient with symptoms and recent travel to Wuhan was en-route to the hospital. Two days later, that patient’s COVID-19 result was confirmed as positive, the first known case in Canada of what was then known as the novel coronavirus.

Right: Two dedicated COVID-19 units opened in anticipation of a potential influx of patients requiring intensive care and respiratory support. Shown here is Julie Nardi, clinical and professional leader for respiratory therapy.

Below: Jenny Jones, a registered nurse in one of our dedicated COVID-19 units, takes a moment to rest as patient volumes increased in April 2020.

Above:. Environmental services team member Angela Corsaro sterilizes a patient room in the critical care unit in March 2020.

Left: The medical team on one of the COVID units prepares to reposition a patient with COVID-19 onto their stomach. The technique, known as proning, helps critically ill patients breathe by allowing more oxygen to enter the blood. 10 HOSPITAL NEWS MARCH 2021


Above: On January 9, 2021, the Shared Hospital Lab (SHL), located at Sunnybrook’s Bayview Campus, processed its one millionth COVID-19 test. SHL is a partnership between Sunnybrook, North York General Hospital, Scarborough Health Network, and Michael Garron Hospital. Left: Physiotherapist Karen Montgomery is shown holding a patient’s hand in the critical care unit.


Michener Institute creates new program in digital health and data analytics he Michener Institute of Education at UHN is creating a new full-time program to meet the needs of the healthcare system for digitally-literate health professionals. The new Digital Health and Data Analytics Program is designed to be pragmatic, practical and job oriented – anticipating the needs of the workplace of the future and using the best education science and methodologies to meet those needs. A combination of in-class teaching and hands-on learning at high-profile public institutions and businesses will give graduates the skills and knowledge to care for patients in an increasingly machine and data-driven healthcare environment. “If we look at what’s happening in healthcare currently, digital health, technology and artificial intelligence are already changing clinical practice and healthcare delivery,” says Harvey


Weingarten, Principal of Michener’s School of Applied Health Sciences. “Our consultations have continually reinforced that there is a serious need for digitally literate and data savvy individuals who understand how healthcare systems work and how healthcare is now delivered.” Key components of the curriculum include: Ý 'LJLWDO KHDOWK LQFOXGLQJ YLUWXDO care, simulation and virtual reality

Ý 'DWD VFLHQFH LQFOXGLQJ WKH DQDO\VLV and use of clinical data Ý 0DFKLQH OHDUQLQJ $, DQG URERWLFV including personalized medicine and ethics Ý 3URMHFW PDQDJHPHQW SURGXFW GHYHOopment and change management Ý 'HVLJQ WKLQNLQJ LQFOXGLQJ XVHU H[perience Ý +DQGV RQ OHDUQLQJ LQFOXGLQJ SUDFWLcums and placements The program is geared toward healthcare providers, graduate students and IT professionals who want to advance their career in healthcare and work on cutting edge digital, analytics and AI healthcare initiatives. The program will be delivered entirely online. Students can sub-specialize in areas such as artificial intelligence DQG URERWLFV DQG FDQ H[LW DIWHU IRXU successful semesters, having met their Post-Diploma Certificate requirements. Those students continu-

ing with the program will have two semesters of workplace practicum H[SHULHQFH LQ DGGLWLRQ WR D SRVVLble sub-specialty course in order to FRPSOHWH WKH VL[ VHPHVWHU $GYDQFHG Diploma program. The Digital Health and Data Analytics programs will begin in September 2021. Enrolment for the full-time program will open in March 2021. Interested candidates can email dhda@ for more information. As Canada’s only “school within D KRVSLWDOÙ GHGLFDWHG H[FOXVLYHO\ WR healthcare education, Michener is uniquely positioned to prepare healthcare professionals in these emerging fields. Michener’s new program will support healthcare professionals at every point in their career pathway through virtual learning, workplace learning, data simulation and modelling, micro-credentialing and collaboH ration with other institutions. Q MARCH 2021 HOSPITAL NEWS 11


Mobilizing a greenfriendly organization

through initiatives large and small or The Hospital for Sick Children (SickKids), no project, initiative or idea is too big or too small when it comes to sustainability. Recognizing its role in contributing to a low-carbon society and ensuring future generations can enjoy a healthy planet, “mobilizing a green-friendly organization” is ingrained into the SickKids 2025 strategic plan. How does SickKids continuously work to improve its standing as a socially and environmentally responsible organization? By getting everybody involved and thinking about sustainability every day. “SickKids has completed a number of impressive environmental initiatives in recent years, including multiple Leadership in Energy and Environmental Design (LEED) certifications for our Peter Gilgan Centre for Research and Learning facility, mass LED lighting retrofits, and we have continued to donate unused medical supplies to clinics around the world,” says Laurie Harrison, Vice-President, Finance and Chief Financial Officer, SickKids. “But equally impressive are the grassroots efforts of our staff and their determination to make a difference any way they can.” SickKids has an in-house “Green Team,” made up of more than 40 dedicated staff members from the hospital and Research Institute, who come up with ways to motivate and engage their SickKids colleagues to be green-friendly. One of their crowning achievements is a series of waste campaigns to raise awareness among staff on proper waste disposal and reduce the amount of waste generated. These multi-week campaigns, which include intranet articles with green facts and recycling tips, focused on one environmentally sensitive item at a time. Here they are so far:



This graphic appeared on corporate screensavers to raise awareness and educate staff about how they can be smart about using, reusing or not using straws. • Reusable mug promotion – the benefits of bringing your own mug on your coffee break (and how to properly dispose of coffee cups if you don’t bring your own) • Plastic bottles vs. reusable bottles – the benefits of drinking water from your own reusable bottle and avoiding plastic • Smart about straws – the benefits of avoiding the use of straws (if you can) and encouraging the use of paper straws; more than 200 staff members pledged to never use plastic straws again. “As the campaigns evolved, the team introduced staff pledges and prizes, and used professionally designed graphics to illustrate best practices,” says Elisabeth Perlikowski, Program Manager, Environmental Sustainability, SickKids. “The overall

aim was to help everyone understand that, by each of us doing a little, our organization can accomplish so much together.” What is particularly heartening is the positive and far-reaching impact these campaigns have had on staff and SickKids. For instance, the SickKids Centre for Global Child Health and the Department of Clinical Dietetics started their own “pro-mug” campaigns to discourage use of disposable cups among their colleagues; the Developmental & Stem Cell Biology, Molecular Medicine and Child Health Evaluative Sciences programs at SickKids Research Institute, which routinely host events with large groups (pre-COVID-19), stopped allowing disposable items for refreshments into their meetings; the use of drinking straws in the Sick-

Kids cafeteria plunged 57 per cent since adopting paper straws and a “request-only” approach for straws to decrease waste. Further, in preparation for the “smart straw” campaign, Nutrition Services stopped distributing a package containing a napkin, straw and multiple utensils automatically with each meal. Instead, the utensils match the meal, which means a serving of soup only comes with a napkin and spoon – no need for a knife and fork too (although COVID-related supply chain issues can sometimes be a challenge). “This is a significant change from a practice that dates back several decades, and with over 100,000 meals served every year, it reduces our environmental footprint, one meal at a time,” says Susan Dello, Senior



Donna Rousell, Registered Nurse, pledged to buy reusable straws for her entire family during a staff educational campaign to be “smart about straws” at SickKids. Here she is with her kids and their reusable metal straws, plus a reusable lunch kit she was awarded as a prize.

Manager, Nutrition Services, adding that a previous initiative by Nutrition Services reduced food waste up to 25 per cent by simply allowing patients to make their own food choices. This is not to say that the larger sustainability initiatives have slowed down – not by any measure. The following remain in full swing: • Ongoing identification and implementation of energy improvements, optimizing the building subsystems performance as well as how they function together • Closing of laboratory fume hoods during off-hours • Enhanced preventive maintenance to fix water leaks • Procuring environmentally sound Forest Stewardship Council certified paper • Increasing on-site bike spaces and resources for staff

• Reusing office supplies and furniture • Constructing a new Patient Support Centre (an education, training and administrative tower) that is part of SickKids Project Horizon with sustainability in mind and targeting LEED certification Mobilizing a green-friendly organization means that sustainability initiatives, large and small, go hand-in-hand at SickKids. Indeed, the next waste campaign is already in the works. “The waste campaigns we’ve completed also result in feedback from staff, who send us ideas about recycling, reducing, and diverting waste,” says Perlikowski. “Our next waste campaign is scheduled to occur during ‘plastic-free July’ and we’re hopeful it will coincide with our cafeteria switching to compostable take-out containH ers and utensils.” ■

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Operation Remote Immunity aims to protect residents from COVID-19 By James MacDonald n a cold morning in Neskantaga First Nation, about 450 kilometres north of Thunder Bay, people lined up early, eager to take part in a clinic that had been weeks in the making. As Chief Chris Moonias stepped into the building, he offered a message of hope through his smartphone. “We come to you live from the Neskantaga Community Centre, where our vaccines will be administered,” said Chief Moonias, speaking to an online audience via Facebook Live. “I’ll be the first one up!” As the camera livestreamed Chief Moonias’ video to his community and beyond, he made his way into a room where a waiting vaccination team had set up a clinic. Not long after, he received his first dose of the Moderna vaccine as cheers erupted throughout the room. Remote, fly-in First Nations communities face unique geographic, social and infrastructure challenges that exacerbate the risks posed by the pandemic. To ensure Indigenous communities and vulnerable populations across remote Northern Ontario are protected from COVID-19, a unique collaboration was formed as a means of providing residents with access to the Moderna vaccine. Neskantaga First Nation was one of the first communities to take part in Operation Remote Immunity, a partnership between Ornge, Ontario’s air ambulance and critical care transport service, and the Nishhawbe Aski Nation (NAN). Vaccination teams under the direction of Ornge will travel to 31 northern, remote NAN communities and the municipality of Moosonee to deliver and administer the vaccine to residents who wish to receive it. All residents age 18 or older are eligible. The official launch of Operation Remote Immunity in late January 2021 was the culmination of six weeks of intense preparation and planning, both


Elder Amelia Whiskeyjack, 99, from Mishkeegogamang First Nation receiving a COVID-19 vaccination in her home to protect herself and her community from COVID-19. In home vaccinations are available to community members with mobility concerns.

inside and outside the communities. Coordinators appointed by individual communities, along with Canadian Rangers, worked to prepare for the arrival of the vaccines and the teams. “We thank the community leadership for allowing our teams to begin this important work, and we appreciate the many residents who are providing their assistance by encouraging participation, setting up the clinics, and translating,” says Dr. Homer Tien,

President and CEO of Ornge. “This effort would not be possible without their support.” In building the vaccination teams, Ornge worked with multiple partners, including Weeneebayko Area Health Authority (WAHA), Indigenous Services Canada, the Northern Ontario School of Medicine, Queen’s University, the University of Toronto, northern Paramedic services and Public Health Units, among others. Each

team typically consisted of a team lead, four other healthcare professionals – including physicians, nurses, paramedics and medical students -and an administrator. Team members received the full COVID-19 vaccine and underwent cultural training prior to their participation. Arrangements needed to be made to fly the vaccination teams safely from three northern hubs into five to seven communities each day. Continued on page 17



Key learnings on infection control a year into the COVID-19 pandemic By Greg Miziolek, President, BD-Canada OVID-19 has been a catalyst. Amid the pandemic, infection control in hospitals and other medical environments have undergone significant change to protect patients, healthcare workers and the public. Hospital-acquired infections, sometimes referred to as healthcare-associated infections (HAIs), are the most frequent adverse events to impact patients.i Common types of HAIs include urinary tract infections (UTI), bloodstream infections (BSI), and infections by organisms such as Clostridioides difficile (C. diff), methicillin-resistant Staphylococcus aureus (MRSA) or Vancomycin-resistant Enterococcus (VRE).ii HAIs posed a major risk to patients and healthcare workers throughout 2019-2020 – 19,591 suffered from UTIs, 1,288 suffered from central line-associated bloodstream infections, and 5,321 suffered from infections due to Clostridium difficile, MRSA or VRE.iii The combined threat of HAIs and COVID-19 has led hospitals to implement stricter measures following the Public Health Agency of Canada’s evidence-informed infection prevention and control guidelines.iv As a leading medical technology company, BD-Canada has been working with organizations across Canada to evolve best practices and deliver the tools and systems needed by infection preventionists in acute care settings. We have seen remarkable changes in both policy and practice, many driven by the unprecedented learnings of this time and could remain in place in a post-pandemic era.


Diagnostics have always been an integral part of infection control but in this period of COVID-19, the quick identification of contagious individuals is paramount to keeping everyone safe. With support from rapid antigen tests such as those read by the BD Veritor™ Plus System, healthcare workers can identify, isolate and treat COVID-19 positive individuals within 15 minutes of administering the test, preventing further spread within the hospital and larger community.

Paired with the widespread use of personal protective equipment (PPE) and the strict enforcement of proper hand hygiene and sanitation,ii pointof-care risk assessment and efficient lab-based PCR testing enables healthcare workers to act fast, while arming them with the information they need to help contain infections – from COVID-19 to the flu and HAIs. There is also now more comprehensive engineering and administrative controls, such as facility design chang-

es and product preparedness. Frequent surface sanitation and handwashing, rigorous isolation practices and measures to reduce unnecessary physical contact today prevent the dangerous spread of COVID-19.ii In the future, such practices, as well as solutions with built-in product preparedness and instruction, may reduce errors that lead to HAIs. Tools like the BD Zero-In™ comprehensive clinical solution program magnify variation in Foley catheter management practices, helping to identify training needs.v,vi Finally, we have seen the vigilant active surveillance and reporting of COVID-19 symptoms among patients, visitors, and healthcare workers.ii With systems in place to screen, surveil and track COVID-19 infections, hospital staff can contain the spread of the virus, minimize its impact, and identify trends and recommendations to avoid future outbreaks. With those same principles and aided by innovative informatics and analytics tools such as BD Healthsight™ Infection Advisor, the proper surveillance and reporting of HAIs can help track interventions and inform process improvements. The pandemic has had devastating impacts on our health system, but it has also afforded us invaluable learnings. As a community, it’s our collective responsibility to ensure these learnings help us improve our practices and protocols long after the COVID-19 virus is eliminated to continually enhance patient outcomes. To learn more about our response to COVID-19 in Canada, visit H Q

i “The Burden of Health Care-associated Infection Worldwide.” World Health Organization. November 21, 2017. Accessed February 08, 2021. burden_hcai/en/. ii Canada, Public Health Agency of. “Government of Canada.” June 29, 2018. Accessed February 08, 2021. iii Discharge Abstract Database, 2014–2015, 2015–2016, 2016–2017, 2017–2018, 2018–2019 and 2019–2020, Canadian Institute for Health Information. iv Canada, Public Health Agency of. “Government of Canada.” January 08, 2021. Accessed February 08, 2021. v BD-Canada. BD Zero-In™ comprehensive clinical solution program brochure. vi Canadian Patient Safety Institute. Hospital Harm Improvement Resource: Urinary Tract Infection. April 2016. Accessed February 10, 2021. toolsResources/Hospital-Harm-Measure/Documents/Resource-Library/HHIR%20UTI.pdf.



Supporting the provincial pandemic response By Altaf Stationwala


his past year, we have seen the health care system manage inconceivable challenges brought on by a global pandemic. We have also seen incredible achievements and daily examples of what the human spirit can accomplish when presented with those challenges. As President and CEO of Mackenzie Health, I know how dedicated our health care workers have been since the start of the pandemic. In the early days of COVID-19, this was a largely unknown virus. Despite being scared for themselves and their families, staff came to work each day to provide the care their patients needed. That unrelenting commitment continues a year later, no matter how hard it has been. The flexibility and nimbleness of our staff has never been more apparent than it was in January 2021 when our team at Mackenzie Health was asked to step up to support the health care system as a whole and change the way we planned to open our long-awaited second hospital. Cortellucci Vaughan Hospital was intended to open on February 7 as Mackenzie Health’s second full-service community hospital, serving Ontario’s western York Region. It’s Canada’s first smart hospital and the first net new hospital to be built in the province in more than 30 years. Instead of fully opening the hospital the way we intended, we opened with an exclusive focus on creating additional ICU and acute care capacity to address the surge in COVID-19 cases in Ontario.


In early January, COVID-19 cases in Ontario were rising at an alarming rate and ICUs across the province were reaching near capacity. Provincial modelling was suggesting that we would reach 500 COVID-19 patients in the ICU by mid-January. There was also news of new variants that had the potential to increase case counts in the community which, in turn, would further impact hospital capacity.

Altaf Stationwala Mackenzie Richmond Hill Hospital, along with many other hospitals across the province, has been able to experience temporary capacity relief thanks to the province’s Incident Management System (IMS) structure which was introduced in November 2020. It was created to help hospitals across the province with capacity pressures by supporting the movement of patients to hospitals with the available resources to care for them. By the end of January, we had transferred more than 70 patients from Mackenzie Richmond Hill Hospital to neighbouring hospitals for care. The province had already activated field hospitals and was looking at other unconventional options that wouldn’t provide the optimal patient experience. Understanding the capacity pressures facing our health care system during this unprecedented time, the Government of Ontario approached Mackenzie Health to provide a unique system solution for the province with a different type of opening for our second hospital. We were proud to step up in this way. We had benefited greatly from the IMS solution, and it was our turn to return the favour.


Cortellucci Vaughan Hospital was scheduled to open as a full-service hospital on February 7, 2021. It was purposefully built with mostly single patient rooms that allow for enhanced

infection prevention and control protocols and technological advances to support the patient experience. It is also ideally located right off Highway 400, in close proximity to the hardest hit regions in the province: York, Peel and Toronto. As our team was in the final stretch getting ready to fully open our new hospital to the community – training more than 3,000 staff across both hospital sites, learning new work flows and testing thousands of pieces of equipment – they were asked to make a shift and change course. Over three weeks leading up to February 7, staff and physicians made final preparations to the critical care and general medicine floors of Cortellucci Vaughan Hospital. Since the Emergency Department at Cortellucci Vaughan Hospital will be closed until the surge is adequately addressed, we were able to redeploy some surgical teams to work in our general medicine units, and some Emergency Department nurses were redeployed to support critical care patients. A key priority was to ensure staff were properly trained and prepared in these new roles. We also had to develop and implement a strong Human Resources communication strategy to support the hundreds of pieces of correspondence necessary to address employment contracts and redeployment assignments as well as continued engagement with our union partners.

The staff at Mackenzie Richmond Hill Hospital also stepped up to support the effort. They made sure that patient transfers to Cortellucci Vaughan Hospital from Mackenzie Richmond Hill Hospital were coordinated in a safe and efficient way. Those working in the departments that were slated to move to Cortellucci Vaughan Hospital, including our Woman and Child, Inpatient Mental Health and Inpatient Integrated Stroke programs, have also been incredibly flexible and adaptable with the change. They will continue to provide care to our community at Mackenzie Richmond Hill Hospital until we can fully open Cortellucci Vaughan Hospital the way we had intended.


On February 7, we opened our critical care and general medicine beds at Cortellucci Vaughan Hospital to support the surge in the system through the IMS structure. Watching that first patient transfer vehicle arrive in our ambulance bay at 7:35 a.m. that Sunday morning was a milestone moment for our organization. Although it wasn’t the type of opening our staff, physicians, volunteers and community had been anticipating, supporting the health care system in this way was the right thing to do. Residents in the City of Vaughan have waited so long for their first hospital to open and they have been waiting years to be able to access all of the services that Cortellucci Vaughan Hospital was intended to offer. Without the understanding and support of the Mackenzie Health team and of the residents in the communities we serve, we wouldn’t have been able to step up in the way we did to support our community and our province through the pandemic. We look forward to being able to fully open Cortellucci Vaughan Hospital the way we originally intended and realize our two-hospital future once the surge is adequately addressed. Until then, we’re proud to be part of the solution as we support the provincial H pandemic response. n

Altaf Stationwala is President and CEO, Mackenzie Health. 16 HOSPITAL NEWS MARCH 2021


Vaccines offer hope in Ontario Continued from page 14 For aviation services, Ornge relied on the Ministry of Natural Resources and Forestry, as well as a number of contracted air carriers, including SkyCare, Air Bravo, Wasaya Airways, Air Creebec and Thunder Air. In parallel to this planning process, public education campaigns carried out by regional partners, including the Sioux Lookout First Nations Health Authority (SLFNHA) and WAHA. These efforts were instrumental in addressing vaccine hesitancy, spreading the word that the vaccines are safe and effective, and encouraging participation among residents. “Vaccination teams are being welcomed in communities across our territory,” says Nishnawbe Aski Nation Grand Chief Alvin Fiddler. “The number of community members giving

Remote, fly-in First Nations communities face unique geographic, social and infrastructure challenges that exacerbate the risks posed by the pandemic. their consent to receive the vaccine is encouraging.” The day-to-day logistics of carrying out this campaign are not without challenges. The harsh winter weather common at this time of year across the north can result in conditions unsuitable for the safe transport of the vaccination teams, resulting in some clinic

postponements. One clinic began its day with a temporary power outage. Even with these challenges, over the first few weeks of the campaign, more than 7,000 people attended clinics to receive their first dose. In Neskantaga, Chief Moonias wrapped up his Facebook livestream as he waited in the clinic an extra 15

minutes post-vaccination as a precaution. His efforts to lead by example concluded on a note of encouragement for thousands of northern Wresidents considering receiving the vaccine. “Let’s protect our communities. Let’s protect our people. Let’s beat H this virus.” ■

James MacDonald is Director of Communications and Public Affairs for Ornge

1-800-811-1148 for assistance across Canada

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Successful health care Energy Lite training seeks second cohort By Krishna Akella and Ken Waddington ound energy management practices are crucial to the efficient running of any health care facility. This means focusing on cost-savings and greenhouse gas emissions reductions while simultaneously ensuring the patient care and staff work environments are safe and comfortable. It was with these ideas in mind that the Canadian Coalition for Green Health Care developed Canadian health care’s newest energy management training program. Together with Ontario’s Independent Electricity System Operator (IESO), Trane Canada and Ecosystem Energy, the Coalition recently delivered its new training program, Energy Lite, to attendees from a broad swath of Canadian health care including en-


ergy and facility managers, engineering staff, building operators, and project managers. Participants from across Canada shared the learning platform with colleagues from as far away as the USA, Trinidad and Tobago and the Republic of Côte d’Ivoire in West Africa. “Raising awareness of energy conservation practices is a very important component in any health care organization’s fight to reduce energy consumption, lower their GHG emissions and make the sector’s delivery of health services more sustainable. The Coalition is very pleased we were able to provide so many health care facility experts with updated and relevant training to help them in their day-today operations. It was a win-win for everyone,” says Coalition Executive

Director Neil Ritchie, who also applauded the work of the development and delivery team. It was imperative that the Energy Lite training employ subject matter experts to deliver timely in-field concepts to the audience. In addition, the training program offered case studies demonstrating sound business case methodologies, a number of guidance documents, and networking opportunities for those in smaller, more remote communities, plus awareness collateral suitable for post-training use in participant sites. Targeted at multiple audience groups including hospital and longterm care staff, industry personnel and government staff, the program was successfully led by an experienced team of facilitators with extensive ex-

perience in Canada’s health services sector. J.J. Knott, Stephen Dixon, and Michel Parent covered a diverse array of topics such as energy-efficient lighting systems, heating, ventilation and air-conditioning (HVAC) system optimization, boiler/steam system optimization, compressor systems, ENERGY STAR®, RETScreen Clean Energy Management Software, the circular economy and behaviour change. The training was well received by the first cohort with 96 per cent indicating they would recommend Energy Lite to a colleague. Currently, the Coalition team is evaluating options for delivery of a second cohort during 2021. There are abundant free energy management resources available on the Coalition’s Energy Lite website at

Are you new to Canada? / Nouvellement arrivé(e) au Canada? Ž LJŽƵ ǁĂŶƚ ƚŽ ŝŵƉƌŽǀĞ LJŽƵƌ ǁŽƌŬƉůĂĐĞ ĐŽŵŵƵŶŝĐĂƟŽŶ ƐŬŝůůƐ͍ PĂƌƟĐŝƉĂƚĞ ŝŶ ĨƌĞĞ KĐĐƵƉĂƟŽŶͲƐƉĞĐŝĮĐ >ĂŶŐƵĂŐĞ dƌĂŝŶŝŶŐ ĐŽƵƌƐĞƐ tŽƌŬƉůĂĐĞ ŽŵŵƵŶŝĐĂƟŽŶ ^ŬŝůůƐ ĨŽƌ ,ĞĂůƚŚ Ăre • Dental HygieniƐt • Medical LaboƌĂƚŽƌLJ dĞĐŚŶŽůŽŐŝƐƚ • DĞĚŝĐĂů ZĂĚŝĂƟŽŶ dĞĐŚŶŽůŽŐŝƐƚ • NurƐĞ • PerƐŽŶĂů ^ƵƉƉŽƌƚ Worker • ^ůĞĞƉ TechnologiƐt

tŽƌŬƉůĂĐĞ ŽŵŵƵŶŝĐĂƟŽŶ ^ŬŝůůƐ ĨŽƌ /nterproĨĞƐƐŝŽŶĂů Health Care TĞĂŵƐ • ŝĞƟƟĂŶ • NurƐĞ • KĐĐƵƉĂƟŽŶĂů dŚĞƌĂƉŝƐƚ • PhyƐŝŽƚŚerapiƐt • ^ŽĐŝĂů Worker

&Žƌ ŵŽƌĞ ŝŶĨŽƌŵĂƟŽŶ ǀŝƐŝƚ ŚƩƉƐ͗ͬ​ͬĐŽͲŽƐůƚ͘ŽƌŐ To qualify, you must have training or experience in the ĮĞůĚƐ ůŝƐƚĞĚ ƵŶĚĞƌ each course, be a ƉĞƌŵĂŶĞŶƚ ƌĞƐŝĚĞŶƚ ŽĨ ĂŶĂĚĂ Žƌ Ă ƉƌŽƚĞĐƚĞĚ ƉĞƌƐŽŶ͕ ĂŶĚ LJŽƵƌ ŶŐůŝƐŚ ŵƵƐƚ ďĞ Ăƚ ĂŶ Intermediate level ; ĂŶĂĚŝĂŶ >ĂŶŐƵĂŐĞ ĞŶĐŚŵĂƌŬƐ ϲ ʹ ϴͿ͘



Green Health Care Awards By Kent Waddington

he 2019 Energy Awards and the Green Health Care Awards were announced Thursday December 10th and Wednesday December 16th respectively, at virtual awards presentations held by the Canadian Coalition for Green Health Care. The awards are made possible with funding from the Independent Electricity System Operator (IESO) and Medtronic. Recognition through the Green Health Care Awards is predicated upon the results of the Green Hospital Scorecard (GHS), which is a comprehensive ‘Made in Canada’ health care benchmarking tool that measures hospitals’ performance in various categories. This year’s awards honoured the top performing Ontario hospitals in Energy, and top performing Canadian hospitals in Water, Waste, Leadership, and Pollution Prevention categories. The hospitals with the highest overall scores in their respective peer groups were presented with the Green Hospital of the Year Award. See below for the list of winners.

T Please feel free to download and share with your colleagues. If you would like to join cohort two, or your company is interested in being part of the planning and delivery of the next Energy Lite sessions, please reach out to Kent Waddington at kent@ for further details. The Canadian Coalition for Green Health Care is a nationally incorporated not-for-profit coalition of health care organisations, a green health care resource network, and a national catalyst for environmental advancement in health care. The Coalition’s vision is that every health care organization in Canada will become a green health care organisation; climate-smart and a champion for the environment. Great energy management can make a world of difference to both facilities, and the environment. The Coalition is working had to preserve the environment, one Energy Lite Online Training session at a time. Learn more at: H www.greenhealth ■ Krishna Akella is the Coalition’s Manager of Digital Marketing and Online Programs. He can be reached at krishna@ and Kent Waddington is the Coalition’s co-founder and Communications Director. He can be reached at

Green Hospital of the Year UHN Toronto Rehab – Academic Michael Garron Hospital – Community Holland Bloorview Kids Rehabilitation Hospital – Non –Acute Kemptville District Hospital – Small Energy Providence Healthcare – Academic

Ross Memorial Hospital – Community St. Joseph’s Health Centre –Parkwood RMHC – Non –Acute Strathroy Middlesex General Hospital – Small Water The Ottawa Hospital – General Hospital – Academic Ross Memorial Hospital – Community The Royal Ottawa Mental Health Centre – Non –Acute Four Counties Health Services – Small Waste Trillium Health Partners –Queensway Health Centre – Academic Ross Memorial Hospital – Community The Royal Ottawa Mental Health Centre – Non –Acute Kemptville District Hospital – Small Leadership University Health Network – Academic Michael Garron Hospital – Community Holland Bloorview Kids Rehabilitation Hospital – Non –Acute Kemptville District Hospital – Small Pollution Prevention St. Michael’s Hospital –Main Building, Bond Street – Academic Markham Stouffville Hospital – Community Holland Bloorview Kids Rehabilitation Hospital – Non –Acute Kemptville District Hospital – Small

Energy Behaviour UHN Toronto General – Academic Originally developed by the Ontario Hospital Association (OHA) eight years ago in conjunction with an advisory committee of hospital staff and staff from the Coalition, the GHS is the only comprehensive environmental health care benchmarking tool in Canada. In 2016 the OHA was interested in finding an appropriate organization to assume management and delivery of the GHS to ensure that the GHS and the Green Health Care Awards program would continue to be available to Ontario hospitals, and subsequently to hospitals across Canada. The OHA approached the Coalition with this opportunity, as the Coalition has been a historic collaborator with the OHA for the past 19 years, not only on the GHS but also on the Green Health Care Awards, and has a long history of effectively promoting environmental sustainability in health care, making it a logical choice to carry forward the delivery of the GHS. The main purpose of the GHS is to provide a vehicle for standardized, sector – specific environmental benchmarking and to connect hospitals with environmental information that will assist them in making decisions to achieve environmental and economic benefits such as reduced greenhouse gas emissions and improved energy and water efficiency. Visit H to learn more about the GHS. ■

Kent Waddington is the Communications Director at the Canadian Coalition for Green Health Care.



Compassionate use:

Access to experimental or unapproved medical interventions By Sarah Abu-Jazar he terms “compassionate use” and “expanded access” are used to describe scenarios in which individuals with serious, rare, emergency, and/or life-threatening conditions are given the opportunity to access drugs or other medical interventions that have not yet been approved for conventional use or sale. These interventions may still be under clinical study, pending approval by relevant regulatory bodies (e.g., Health Canada), or they may be unavailable for use. The purpose of obtaining access to an unapproved or experimental drug or medical intervention is typically that it may provide individuals with some therapeutic benefit when all other options have been exhausted (i.e., available treatments have not been effective or are unsuitable) and/or if they are ineligible to participate in a clinical trial. For instance, suppose that an eightyear-old old child is diagnosed with a rare congenital condition that causes developmental delays and that there are no approved medical treatments. However, a clinical trial is testing a drug that has shown promise in controlling the biological pathways that contribute to the condition. The clinical trial only includes children over the age of twelve, but the child’s parents want them to gain access to the drug through a compassionate use program because the trial will end by the time their child becomes eligible. To consider another hypothetical example: Suppose that someone by the name of Julie was diagnosed with a rare type of sarcoma (i.e., a type of cancer). Julie has undergone various treatments, including surgeries, chemotherapy, and radiation. Although these treatments have resulted in temporary improvements, her condition remains


THERE ARE MANY ETHICAL CONSIDERATIONS TO TAKE INTO ACCOUNT WHEN IT COMES TO COMPASSIONATE USE, SUCH AS WEIGHING POTENTIAL BENEFITS VERSUS POTENTIAL (AND SOMETIMES UNKNOWN) HARMS AND UPHOLDING PATIENT AUTONOMY. present and she is unlikely to receive any long-term relief. Through doing some research about alternate treatments, Julie learns that there is a drug available in another country that has shown evidence of tumor regression in patients with her type of cancer. However, this drug is not approved for use in her country. Julie asks her physician for access to the drug through a compassionate use program. The Special Access Programme (SAP) is the regulatory body in Canada that allows clinicians to request medical interventions for their patients under the umbrella of “compassionate use”. When applying for access through this program, evidence of efficacy from scientific literature and from the manufacturer must be presented, and clinicians are responsible for informing their patients about the risks and benefits of the medical intervention. If approval is obtained from the SAP, then the manufacturer of the drug or medical device may choose to sell it to the physician’s institution for the requested use. Compassionate use approval does not guarantee that the manufacturer will authorize use of the drug or medical device outside of the clinical trial and/or be willing to ship it to another country. The process of seeking compassionate use approval, manufacturer approval, and gaining access can take a significant amount of time.

It is important to keep in mind that the practice of compassionate use does not come without risk; this is especially the case when it comes to medical interventions that are still under clinical trial. By virtue of the drug or medical intervention being studied, its efficacy in providing therapeutic benefit is not guaranteed, and any risks or potential harms have not been confirmed. As such, it is possible that the individual seeking access may not experience any benefit and/or may experience substantial harm. It may also be the case that their condition could worsen. It is also important to note that new information about the experimental intervention may arise at any point during trial, including serious side effects. This may be the case even if it has been approved in other parts of the world since different health regulatory bodies have different standards for safety and efficacy. A number of ethical considerations and concerns exist when thinking about compassionate use programs. One of these concerns involves patient autonomy and decision-making capacity. Since patients who seek compassionate use have exhausted all other treatment options, and since their condition is rare, life-threatening and/or debilitating, it is possible that they may be unable to accurately evaluate the risks and benefits of the

drug or intervention; the sense of urgency to get better, in addition to any corresponding vulnerabilities, may influence their decision-making capacity. SAP regulations emphasize that it is important for clinicians to support the decision-making process by ensuring that their patients fully understand the pros and cons of expanded access based on their condition and goals of care. Another concern about compassionate use involves the possible lack of patient oversight, where individuals who access experimental or unapproved medical interventions may not receive the same level of oversight and protection as clinical trial participants. Nonetheless, compassionate use programs (such as the SAP) do systematically review individual applications and previous uses of the intervention. They also collect mandatory reports from clinicians on the outcomes of the interventions used through the program. Another obstacle that patients may encounter when trying to access an experimental or unapproved treatment through compassionate use is that its cost is not covered by the manufacturer – it may need to be purchased by the physician, the medical institution, and/or the patient. In short, there are many ethical considerations to take into account when it comes to compassionate use, such as weighing potential benefits versus potential (and sometimes unknown) harms and upholding patient autonomy. Ultimately, it is worth considering strategies that can be put in place to minimize harm to patients, support their right to make autonomous decisions even if risks are present, and to facilitate compassionate H use access if approval is granted. ■

Sarah Abu-Jazar, MHSc, is currently a Research Compliance Specialist at Khalifa University’s College of Medicine and Health Sciences. 20 HOSPITAL NEWS MARCH 2021





COVID-19 vaccine hesitancy among healthcare workers By Jennifer Happe he World Health Organization identified vaccine hesitancy, the reluctance or refusal to vaccinate despite the availability of vaccines, as one of the top 10 threats to global health in 2019. Vaccine uptake is essential to safeguard human lives and curb the socio-economic impact of the current COVID-19 pandemic. However, Statistics Canada reports that only 57.5 per cent of Canadians are very likely to get vaccinated against COVID-19. Healthcare workers are among those reluctant to be vaccinated. Chief concerns include lack of confidence in vaccine safety, concern about risks and side effects of the vaccine and mistrust of the public health care system.


Jennifer Happe The Government of Canada launched the COVID-19 Immu-

nity Task Force (CITF) to track COVID-19 among Canadians and priority sub-groups including healthcare workers. While CITF studies are still ongoing, data from the United States of America and the United Kingdom suggest the risk of COVID-19 among healthcare workers is three times higher than the general population. Protecting the health and wellness of healthcare workers is vital to maintain a functioning healthcare system. Overcoming vaccine hesitancy is an important strategy to ensure healthcare worker safety. One method to overcome vaccine hesitancy is mandating vaccination, either by government regulation or through terms of employment. Mandating COVID-19 vaccination

is controversial and subject to challenge under the Canadian Charter of Rights and Freedoms. Alternately, vaccine confidence can be fostered with education and training using scientific evidence on vaccine efficacy, safety, its role in COVID-19 prevention and the government evaluation and approval process. Education efforts should focus on exposing and explaining misinformation and coaching workers on how to identify misinformation. Healthcare workers themselves have a responsibility to seek accurate information from reliable sources for a fulsome understanding of COVID-19 vaccines. For more information on Canada’s COVID-19 vaccine strategy and vaccine efficacy and safety, visit H ■

Jennifer Happe, M.Sc. is the Director, Infection Prevention and Control Canada.

Can light therapy be used to treat early stages of COVID-19? By Samantha Sexton team of researchers from Sunnybrook Research Institute and University Health Network is investigating whether a form of light therapy, commonly used to eliminate harmful bacteria from surgical patients, can also be used to destroy COVID-19. “Methylene blue photodisinfection (PDT) is a highly effective and safe treatment that uses the local application of a non-toxic dye, activated by light, to destroy harmful bacteria and viruses,” says Dr. Cari Whyne, one of the principal investigators of the study and research director of the Holland Bone and Joint Research Program at Sunnybrook Research Institute. “PDT is safe, low-cost and minimally invasive, making it an exciting option to potentially reduce the spread of SARS-CoV-2, the virus that causes COVID-19.” The trial, funded in part by the Ontario government’s COVID-19 Rapid


Research Fund, is aiming to evaluate the potential of the light therapy in people who have recently tested positive for COVID-19. The research team is working with Canadian company, Ondine Biomedical, who developed the Steriwave™ photodisinfection technology used in the study. During a study visit, participants have the inside of the front part of their nose swabbed for a baseline measure of virus particles present. The treatment is performed by applying the methylene blue photosensitizer to the inside of the nostrils and placing a light source for a few minutes. Following this, a second swab of the nose is taken to measure how effectively the light therapy has inactivated the virus. “There’s still so much to know about coronavirus, so why not help learn more by participating in a safe research study? I just want to help defeat this pandemic,” said one participant in the study.

Researchers are investigating whether a form of light therapy, commonly used to eliminate harmful bacteria from surgical patients, can also be used to destroy COVID-19.

In addition to quantifying the amount of virus particles present after photodisinfection, the researchers have also been conducting pre-clinical research to establish the best amounts of photosensitizer and light doses necessary to kill SARS-CoV-2. Although the study is still in its early stages, the research team sees possible implications for the light therapy,

if it proves successful. “We’re excited about the potential of photodisinfection from a few standpoints — preventatively for people visiting a high-risk area or for those who have recently been exposed or are at an early stage of infection,” says Dr. Brian Wilson, co-principal investigator of the study and a senior scientist at University H Health Network, Toronto. ■

Samantha Sexton is a Communications Advisor, Sunnybrook Research Institute Sunnybrook Health Sciences Centre. 22 HOSPITAL NEWS MARCH 2021


Dave Williams

Linda Duxbury


Bonnie Henry


Infection Prevention and Control Professionals and healthcare providers interested in the prevention and control of infections in all healthcare settings.

J O I N U S A N D H E L P C E L E B R AT E I PA C C A N A D A ’ S 4 5 T H A N N I V E R S A R Y



Thinking outside the box to bring families together By Carrie Stefanson hipping containers are used in a variety of ways, from transporting cargo to being stacked to form ultra-modern apartments. Queen’s Park Care Centre is using an upcycled container to connect families with loved ones in care. The container – now known as the Visitor Centre, accommodates private, yet distanced visits for one resident and up to four visitors at a time. The visits follow all public health guidelines. The shipping container is heated and furnished, with separate entrances for residents and families. A plexiglass partition separates the two spaces.


“It’s an innovative way to bring families together,” says Karl Segnoe, whose 92-year-old grandmother lives at Queen’s Park Care Centre. “I have every confidence in the staff to keep my grandmother safe, but I fear social isolation is taking a toll on her well-being. Being able to visit as a family is huge because my grandmother is such an important person in our lives.” Up until now, families wishing to visit their loved one together could do so via a window visit, where a health care worker brings a resident to a window at a specified time for a visit. The visitor centre is an alternative to window visits, providing a dry, warm place

The Medco Clean Room on Wheels! Medco Equipment Inc.’s multi-purpose automatic equipment washer model 64X washes and sanitizes up to twenty wheelchairs ǣȇ Ȓȇƺ ǝȒɖȸِ ȇ ǣȇƳƺȵƺȇƳƺȇɎ ǼƏƫ ƬȒȇˡȸȅɀ ‫ ۏחِחח‬ȸƺƳɖƬɎǣȒȇ of bacteria after one 5 minute wash! The all - purpose washer sanitizes wheelchairs, commode chairs, shower chairs, walkers, carts etc. No special plumbing or electric is needed. Standard ǕƏȸƳƺȇ ǝȒɀƺ ˡɎɎǣȇǕɀ ƏȇƳ ɀɎƏȇƳƏȸƳ ‫׎׏׏‬ɮ ȵǼɖǕ ǣȇِ ³ǣȅȵǼƺ Ȓȇƺ button operation. The germ killing detergent and rinse agents Əȸƺ ƏɖɎȒȅƏɎǣƬƏǼǼɵ ƳǣɀȵƺȇɀƺƳ ɯǣɎǝ Ȓɮƺȸ Ɏǝȸƺƺ ǝɖȇƳȸƺƳ ɯƏɀǝƺɀ ȵƺȸ ǕƏǼǼȒȇ Ȓǔ ƬǝƺȅǣƬƏǼِ Áǝƺ ɯƏɀǝƺȸ ǣɀ ƫɖǣǼɎ ɯǣɎǝ ǝƺƏɮɵ ƳɖɎɵ ǔȒȒƳ ǕȸƏƳƺ ɀɎƏǣȇǼƺɀɀ ɀɎƺƺǼ ƏȇƳ ǔȒɖȸ ɀɯǣɮƺǼ ٖǼȒƬǸǣȇǕ ƬƏɀɎȒȸɀ ȅƏǸǣȇǕ ǣɎ ƺƏɀɵ ɎȒ ɎȸƏȇɀȵȒȸɎِ Áǝƺ ɯƏɀǝƺȸ ǣȇƬǼɖƳƺɀ Əȇ ِ³ِRِ ِ ƏȵȵȸȒɮƺƳ front door handle that can be operated from outside and inside the washer. It also includes an emergency stop button (E-Stop), safety door switch (auto off if opened), solid state electronics, ‫ ד‬ɵƺƏȸ ɯƏǼǼ ɎȒ ɯƏǼǼ ɯƏȸȸƏȇɎɵً !0ً Ènً !ٖÈn ǼǣɀɎƺƳِ Áǝƺ ɯƏɀǝƺȸ ƳǣȅƺȇɀǣȒȇɀ Əȸƺ ƏȵȵȸȒɴǣȅƏɎƺǼɵ ‫ ټב‬ɯǣƳƺ ‫ ټד‬ɎƏǼǼ ɴ ‫ ټד‬ǼȒȇǕِ ɮƺȸ ‫ ׎׎׎ًא‬ ƬɖɀɎȒȅƺȸɀ ɯȒȸǼƳɯǣƳƺٍ ȳ ǕȒɮƺȸȇȅƺȇɎ ƏȵȵȸȒɮƺƳِ For more information please call 1-800-717-3626 or visit us on the web


Taimi Norberg visits her grandson, Karl Segnoe, and his room-mates.

THE CONTAINER – NOW KNOWN AS THE VISITOR CENTRE, ACCOMMODATES PRIVATE, YET DISTANCED VISITS FOR ONE RESIDENT AND UP TO FOUR VISITORS AT A TIME. to have a window visit with residents and patients. Window visits will continue for larger groups, as will virtual visits. “Residents in long term care and their families have endured so much during the pandemic,” says Dr. Victoria Lee, president and CEO, Fraser Health. “I’m grateful to the Queen’s Park Healthcare Foundation for helping us move this project forward so families can connect with their loved ones in this unique way.” It was an idea from staff at Queen’s Park Care Centre that

prompted Elizabeth Kelly, the executive director of the Queen’s Park Healthcare Foundation, to get the ball rolling. “We had the space, so I applied for a $25,000 federal grant,” says Kelly. “All of us at Queen’s Park Care Centre are looking forward to the day when COVID-19 is behind us and we can remove the partition in the visitor centre so families can celebrate together and hug each other. The pandemic has taught us that the small things in life are really the most H important.” ■

The shipping container where residents can visit loved ones. Carrie Stefanson is senior consultant, Communications and Public Affairs at Fraser Health in British Columbia.


Dr. Susy Hota is Medical Director, Infection Prevention and Control, University Health Network.

From the front lines of a

pandemic By Dr. Susy Hota think if you asked most people on the frontline of this pandemic, they would tell you it’s hard to find the time or energy for reflection. It’s been a year since the WHO declared the COVID-19 pandemic and we’re still in the middle of it. It’s tough to accept because every single one of us is longing for life before the mass quarantine, the deaths, the masks, and the end of everything that signified our usual lives.



Every time we hear transmission rates have gone down, hospitals are slightly less full, and the government is considering yet another re-opening plan, we assume we are winning this fight. The public wants to believe we are winning this fight. Here’s the thing though, it’s been a year and the fight keeps changing. We didn’t know anything last March – we were working in the dark, and the stories out of China initially, and then Europe and then New York just across the border, were frightening. In some countries in Europe and in the United States there

were concerns over sufficient supply of PPE for the health-care workers and fear that there weren’t enough ventilators for the most seriously ill patients. We were staring into the abyss. A year later, there was palpable relief when vaccines were produced in a period of time unheard of in modern medicine. It was a light at the end of this long and dark tunnel. However, months later, we are struggling to effectively deploy stuttering supplies of the vaccines, at the same time that new variants are causing great concern. Should our kids be in

school? How will we help small businesses? What about those without secure housing? How do we protect our elderly in long-term care? And of course, how do we support our staff, family and friends to continue pushing through the pandemic and adhering to infection control measures? Like virtually everyone else I know, these are the questions that keep me awake at night. As the medical director of UHN’s Infection Prevention and Control team, I can say we are old pros at managing infectious diseases. The IPAC team has handled countless

INFECTION CONTROL 2021 breaks of respiratory infections, provided guidance as UHN became the national repatriation site for Ebola in 2014 and I can honestly say we handle this stuff well. But none of the previous outbreaks or pandemics hit us this hard, or for this long. Every single day we are dealing with something new and the way we respond has to change in order to keep up. It’s a whole new world. Every member of our IPAC team has been working day and night to ensure units have what they need to be safe. Surveillance and reporting of COVID-19 cases during and outside of outbreaks, and contact tracing exposed individuals so that isolation and testing can be employed to limit transmission are labour-intensive but critical. These actions don’t respect the boundaries of a work-day – they bleed into nights, weekends and holidays. The IPAC team is also put in the position of having to be the bearer of bad news to their friends and colleagues in order to keep them safe. COVID-19

THROUGHOUT THIS EXPERIENCE I HAVE BEEN REMINDED AT ALMOST EVERY TURN, OF HOW COMMITTED, AND PROFESSIONAL OUR HEALTH-CARE WORKERS HAVE BEEN, AND CONTINUE TO BE. steals joy in so many ways. For healthcare workers who are awfully tired and still working so hard, it’s a terrible thing to have to tell them, you can’t sit and take a break with a friend. You can’t share a treat that might lift your spirits. Everyone has to be superhuman in their vigilance. I find all of that enormously challenging because I know what toll this pandemic is taking on everyone. Perhaps the most emotionally difficult part of this experience has been our work with long-term care homes. In the spring of 2020, UHN was assigned responsibility to support IPAC for 13 long term care centres, five retirement homes, and 30 congregate

care settings. Having no prior experience with LTC, the experience has been eye-opening on many fronts. There was little in the way of IPAC infrastructure and training in the homes. We had to work on building capacity while guiding them through some of the most challenging outbreaks I have ever seen. It was heartbreaking. It’s intense, 24/7 work that requires constant pivoting. Eventually we are going to have to stop treating this as an emergency and figure out how to live with COVID-19 long term. Perhaps we’re not quite ready for that conversation yet because the pandemic still feels very active and volatile, but we’re going to have to get there. And I know

we can. I have watched health-care workers do the most incredible things this past year. Fighting for their patients, even as they fight fear for themselves. Holding hands while people took their last breath. Ensuring loved ones knew they weren’t alone. Working together as a team to inspire each other and get through another really hard day. This has been the toughest professional challenge of my life, and truthfully I just want it to be over. But even on the bleakest days I am reminded of how lucky I am. I have an incredible husband, beautiful and resilient children, and colleagues I would never trade. There are few silver linings in all this, but I try and remember to be grateful for all of them. Throughout this experience I have been reminded at almost every turn, of how committed, and professional our health-care workers have been, and continue to be. We will get through to the other side of this, because of H them. ■

Dr. Susy Hota is Medical Director, Infection Prevention and Control (IPAC), University Health Network.

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It’s time to talk about vaccine hesitancy By Dr. Samantha Hill and many doctors, have taken to social media and other channels, excited to receive the COVID-19 vaccine. But the other day in the operating room, a very smart and amazing scrub tech told me he doesn’t want to get the vaccine “just yet.” He wants to wait a year, to see if there are any unintended consequences. I was shocked. In fact, I initially thought he was joking. He wasn’t. It’s a recurring conversation, and while this is surprising to me and many other doctors, it seems that there is a significant portion of the population that feels the same way. Vaccine hesitancy is not new. In 2019, the World Health Organization called vaccine hesitancy one of the top 10 global health threats. It said that


vaccines prevent two to three million deaths yearly, a number that could increase by 1.5 million if worldwide coverage improved. That was before the COVID-19 pandemic swept across the world, devastating countries, economies and families.

VACCINES PREVENT TWO TO THREE MILLION DEATHS YEARLY With minimal currently accepted therapeutic options available to treat COVID and avert tragic outcomes, an ounce of prevention may be worth far more than a pound of cure. Of course, at present, prevention is all about adhering to public health measures of physical distancing, masking, and practicing proper hand hygiene. But as vaccine supply becomes more widely available,



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getting as many people as possible vaccinated as rapidly as possible will become an essential part of Ontario’s recovery at all levels. I’ve written before about the need to approach these conversations with empathy and openness. Polarizing hu-

man beings into pro-vax and anti-vax camps only entrenches people in their positions and gets in the way of conversation, education, mutual understanding and respect. Ultimately, as a society, we uphold body autonomy, free choice and the right to make –for ourselves –medical decisions that affect us. It gets tricky around vaccines of course, because our choices also affect others, their risks and their lives. For many, getting vaccinated is an expected part of our social contract as Canadians; the same contract that stops us at red lights even when we are in a rush and gives us access to schools and health care. The urgency to vaccinate is rooted in the fact that we need to immunize approximately 65-70 per cent of the population as rapidly as possible to prevent unnecessary loss of life. It’s a massive venture and having individual conversations about risk and benefit is time consuming. It behooves us to examine some of the factors that play into this conversation. Some of the mistrust surrounding vaccines stems from personal experiences, some of it relates to cultural experiences. Members of Black communities remember the Tuskegee experiment, an unethical 40-year study that left syphilis untreated in black men, who believed they were getting free health care. Members of the Black community continue to experience persistent structural inequities daily in their health-care experiences. Members of our Indigenous communities remember residential schools and regularly experience disrespect toward their cultural medicines and attempts to impose non-In-

digenous norms upon them. These are systemic issues reflecting fundamental issues around fairness and equity in health-care delivery. Difficult conversations and visible systemic actions to resolve the inequities must occur. Furthermore, “nothing about us without us” carries exceptional importance here – including community members with lived experiences in the planning and discussions is an essential element. I’m not the first to raise these ideas and I won’t be the last. The Royal College of Physicians and Surgeons of Canada issued this statement on cultural safety guidance for clinicians during the pandemic. The First Nations Health Authority and Research Ethics BC have developed information on culturally safe and trauma-informed practices for researchers during COVID-19. The Canadian Foundation for Healthcare Improvement has also talked about the new reality of culturally safe practices during COVID. Ensuring that vaccines are easily available is another key component to ensuring compliance. For many, being required to go to the hospitals charged with administering the COVID vaccines is incredibly inconvenient, required significant transit time and resulting in the loss of a day’s income. Getting vaccinated must be easy and must not impose financial or other burdens. We must also acknowledge the widespread misinformation surrounding the COVID vaccine. Social media has made it very hard to contain conversations to scientifically grounded fora. According to data collected by Advanced Symbolics Inc., misinformation about the COVID vaccine is spreading among all age groups in Ontario on social media. Doubts and misinformation about how thoroughly the vaccines were tested or the extend of side effects are being shared widely on social media, especially among people under 25 and those between 25 and 34. The most interesting headlines and the most click-inducing links are ones that evoke emotional responses. Continued on page 30


Vaccine hesitancy Continued from page 28 Unfortunately, this is a breeding ground for conspiracy theories and other misinformation. Even in the less extreme headlines, people argue they don’t need the vaccine because they aren’t at risk. They don’t seem to understand the impact of the longterm effects for those who survive COVID and they don’t seem to realize that getting vaccinated will save others’ lives – perhaps even those of loved ones. Those who worry the vaccine was rolled out too quickly and isn’t safe need to understand that it was rigorously tested – possibly more so than many other vaccines prior to use – and that the ongoing collection of data demonstrates exceptional safety. And those who worry that their underlying conditions may make it unsafe to get the vaccine need to know that there are very few contraindica-

Dr. Samantha Hill tions and that they should talk to their doctor about their individual circumstances. Their trusted physicians are key in counselling and educating, as well as in administering vaccines.

As we move forward, supply will cease to be the limiting factor; getting vaccines into arms will depend on administration planning and population buy-in. For the sake of us all, I hope

we will have already had these conversations with our patients, colleagues and leaders. Vaccination delays will cost lives. We’ve lost too many people H already. ■

Dr. Samantha Hill is a cardiac surgeon and President of the Ontario Medical Association

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Research from UHN reveals the

fraction of asymptomatic hospital staff exposed to, infected with SARS-Cov-2 study from UHN, Canada’s largest research hospital, reveals the percentage of symptomatic and asymptomatic healthcare workers infected with the novel coronavirus. “A key question that we wanted to answer was ‘how many asymptomatic healthcare workers are unknowingly infectious or have been exposed to the virus,” says Dr. Deepali Kumar, senior author and a clinician investigator at the Toronto General Hospital Research Institute (TGHRI). To answer this question, two tests were used: swab tests, to see if the virus was present and able to spread; and blood antibody tests, to see if past exposure to the virus had occurred.


A KEY QUESTION THAT WE WANTED TO ANSWER WAS ‘HOW MANY ASYMPTOMATIC HEALTHCARE WORKERS ARE UNKNOWINGLY INFECTIOUS OR HAVE BEEN EXPOSED TO THE VIRUS. The results revealed that, of symptom-free staff, around 0.5 per cent had positive swab tests. This means that around one out of every 200 staff were potentially infectious. When staff had symptoms, that number jumped to 3.4 per cent, or around seven out of every 200 individuals. Using blood antibody tests, the research team found that between

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1.4 per cent to 3.4 per cent of symptom-free staff tested positive, depending on which antibody test was used. “This means that somewhere between three and seven staff out of every 200 had been infected with the virus without ever reporting symptoms,” says Dr. Victor Ferreira, the first author of the study and a scientific associate at TGHRI, where he works

with Senior Scientist and co-author Dr. Atul Humar. Symptoms that were considered were fever, headache, new or worsening cough, shortness of breath, sore throat, runny nose, pink eye, diarrhea, loss of sense of smell or muscle aches. “Our findings reaffirm the importance of remaining vigilant in the screening of health care and other front line workers regardless of whether they experience COVID-19-like symptoms,” says Dr. Ferreira. These results come from the first phase of the study called Research Platform to Screen and Protect Healthcare Workers study – or RESPECT for short, which enrolled front-line health care workers at UHN between March


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INFECTION CONTROL 2021 and June 2020. Given the success of the first phase, RESPECT 2.0 has since been initiated and expanded to include broader clinical personnel, research personnel and other workers, such as those in the food industry. “This observational study has important implications for infection control, as well as staff and patient safety. And it could not have been possible without the multidisciplinary team of physicians, researchers, nurses and other allied health professionals that contributed. Thank you to everyone at TeamUHN that made this possible,” says Dr. Brad Wouters, UHN’s EVP of Science and Research. The study was funded by the Mount Sinai Hospital and University Health Network Academic Medical Organization, the Ontario Institute for Cancer Research, the Government of Ontario, and the Toronto General & Western Hospital Foundation. T Pugh is a Tier 2 Canada Research Chair (CRC); M Cybulsky and B Wouters H are Tier 1 CRCs. ■

Photo: UHN StRIDe Team

Regardless of whether individuals have COVID-19 symptoms, everyone entering UHN is required to wear a medical mask, which is provided during entrance screening—a policy that aims to help prevent asymptomatic spread

This article was provided by University Health Network.

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Most instructions for inserting COVID-19 nasopharyngeal swabs don’t go deep enough, research finds By Crystal Mackay here are wide discrepancies in the instructions for how deep the nasopharyngeal swabs used to test for COVID-19 are to be inserted up Canadian noses, new research from Western University and Lawson Health Research Institute has found. As an otolaryngologist Dr. Leigh Sowerby is an expert in the anatomy of the head, neck and inside of the nose. Using that expertise, he and his colleagues examined the COVID-19 testing instructions provided by provincial and territorial authorities and found wide variations. They reported their findings in the Journal of Otolaryngology – Head & Neck Surgery. “As a surgeon who works inside the nose all the time, I was surprised to find that most of the instructions in Canada aren’t effective to reach the nasopharynx; they just don’t go deep enough into the nasal cavity,”


says Sowerby, an associate professor at Western’s Schulich School of Medicine & Dentistry and Scientist at Lawson Health Research Institute.


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To perform a nasopharyngeal test, the swab must be inserted far enough into the nasal cavity to reach the nasopharynx, the upper part of the pharynx at the top of the throat behind the nose. Samples from the nasopharynx have been shown to be the most sensitive for COVID-19 testing, and are considered the gold standard.

AS A SURGEON WHO WORKS INSIDE THE NOSE ALL THE TIME, I WAS SURPRISED TO FIND THAT MOST OF THE INSTRUCTIONS IN CANADA AREN’T EFFECTIVE TO REACH THE NASOPHARYNX. However, less than a quarter of provincial and territorial public health instructions tell practitioners to insert the swab deep enough to reach the nasopharynx, Sowerby says. The research found that six provinces and territories, including the Northwest Territories, Nunavut, Ontario, Saskatchewan, Prince Edward

Island and Alberta, recommended that the swab be inserted to a depth of four centimetres, or half the distance from nostril to ear. This depth only reaches the mid-nasal cavity, not the nasopharynx, he adds. British Columbia and Manitoba recommended a seven-centimetre depth of insertion, which is still not enough – only reaching the posterior nasal cavity but not the nasopharynx. In Nova Scotia and Newfoundland, the recommended depth of insertion was two-thirds of the distance from nostril to ear, which would effectively reach the nasopharynx, as would following the instructions in New Brunswick and Yukon to insert the swab from nostril to external ear canal. “If we are doing what we are calling a nasopharyngeal swab, the technique for that should be standardized; there is no reason why there should be so much variability,” Sowerby says. “The take-home message is that if we want the most accurate test results, there is room for improvement in the test instructions. Otolaryngologists have a role to play, as we can provide a great service by actively engaging with our local and regional health authorities to train on proper technique and anH atomical knowledge.” ■

Crystal Mackay is the Sr. Media Relations Officer at Western University’s Schulich School of Medicine & Dentistry.


Dr. Heyne using the methylene blue solution on a mask in her lab.

Photo credit: Riley Brandt/University of Calgary.

Light kills. SARS-CoV-2, that is. By Belinda Heyne and Lacey Duffy new, safe, and affordable SARS-CoV-2 decontamination method has been identified and is now being commercially tested and developed for masks and Personal Protective Equipment (PPE). This method works perpetually, even while a mask is being worn. This novel decontamination method relies solely on protective dyes, indoor light, and ever-present oxygen. The DeMaND study co-authored by 52 researchers worldwide with support from 13 labs and institutions, including the WHO, AHS, CDC, University of Calgary, University of Alberta, Québec-Université Laval, Stanford, and the University of Washington, was recently pre-published. For the



first time, Methylene Blue (MB), a Light-Activated Dye was shown to inactivate SARS-CoV-2 on a variety of commonly used masks while keeping their integrity. This Light-Activated Dye, when applied to coronavirus-infected masks, consistently decontaminated SARSCoV-2 from the masks within 30 minutes and in many cases in less than five minutes. Further, masks pre-treated with Methylene Blue provided ongoing decontamination once exposed to SARS-CoV-2.


Based on principles of Photodynamic Therapy used medically for roughly

a hundred years in treatment of cancer, skin and eye conditions, research confirmed the hypothesis of Dr. James Chen that Light-Activated Dyes could destroy SARS-CoV-2 on masks and other PPE. Methylene Blue (MB), and other Light-Activated Dyes, have the unique molecular ability to transfer energy from surrounding indoor light to nearby oxygen, briefly exciting such to the state of singlet oxygen. Singlet oxygen is well-known for its ability to destroy pathogens, including viruses, bacteria, and fungi. The beauty of singlet oxygen is it either reacts with pathogens around it or it reverts back to oxygen. All of this happens within milliseconds. When singlet oxygen comes into contact with coronavirus, it can react

with the virus in many ways: with the amino acids in the spike proteins, in the membrane’s lipids, and with the RNA. It’s not selective but has a preference for certain amino acids in the spike proteins. The study concluded MB (at various concentrations) and light decontaminated SARS-CoV-2 with up to a 5-log reduction of viral load to undetectable levels. Though bright light led to 99.9 per cent inactivation in as little as five minutes (the lowest amount of time measured), even MB exposure to ambient light (700 lux) led to complete virus inactivation after 30 minutes. This research suggests it is now possible for healthcare workers going about their daily routines in typical

INFECTION CONTROL 2021 hospital settings to be exposed to enough light to activate the MB on their pre-treated masks and inactivate any present or forthcoming pathogens.


Effective decontamination methods have become increasingly important for health systems facing PPE shortages and requiring reuse of PPE, and the pandemic has demonstrated the need to improve the technology and performance of masks and PPE to provide better protection to frontline health workers. Many health systems rely on the expensive and extensive UV Light or Vaporized Hydrogen Peroxide decontamination methods at best, and seven days of storage in brown paper bags at worst. The MB + Light method requires no specialized equipment or energy resources and will represent a more affordable option when products are made available. Further, since PPE pre-treated with MB was shown to offer ongoing inactiva-

tion of coronavirus and other pathogens during use, masks could be made more effective with this technology. Compared to current N95s and similar masks that trap pathogens, wearers of masks pre-treated with MB could benefit from an active line of defense against such pathogens. This technology could represent the next line of improvement for hospitals, nursing homes, home health – all healthcare systems.


Leading virologists, chemists, and researchers around the world are presently conducting follow-up studies. Though the science is simple and the concept is proven, special attention to the chemistry of these protective dyes is important, from choosing the optimum protective dyes, to determining dosing concentrations, to measuring singlet oxygen production. Certain dyes can be optimized for specific lighting conditions, environments, use H cases, and desired outcomes. ■

Dr. Heyne completed her post-doctoral fellowship at the University of Ottawa. In 2007, she began her career at the University of Calgary, where she is now a Full Professor. Lacey Duffey received an MA in Journalism from University of Oklahoma, she is currently VP Experience at Singletto.



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Mobile vaccine team helps inoculate some of the most vulnerable against COVID-19 elief takes various forms – clapping, tears of joy, chants of “the vaccine is here, the vaccine is here!” After months of desperately battling COVID-19, residents, staff and essential caregivers at long-term care centres, retirement homes and congregate living settings across Toronto rang in the new year by receiving their first dose of the Moderna vaccine. “You could sense the sheer joy from people in the room as they were getting this protection,” says Inthuja Kanagasabapathy, a registered nurse (RN) with the Family Health Team at Toronto Western Hospital (TWH). She was part of the UHN mobile vaccine team that administered the first doses of Moderna to long-term care (LTC) residents in Ontario on the last day of 2020. “It’s been tough for them for many months but now they have the vaccines, and with them, hope. It’s truly an honour for us to be part of this. We are so proud of the teamwork that’s gone into it. And, hearing the feedback from recipients, their smiles and thank yous, is overwhelming to see.” It’s an effort that’s brought together Toronto Public Health, city staff and teams from nine hospitals and about 160 LTCs, retirement homes and congregate living sites, to protect Toronto’s most vulnerable. “Long-term care is where the biggest amount of death and suffering has been so being able to get there with help and hope is such a positive thing that really resonates with people,” he says. “The teams are tired but the thing that buoys them along is the gratitude they encounter when they arrive.” Mobile Team Vaccine came together quickly. UHN provides the backbone support for the coalition of partners and is the central supply depot for Moderna in Toronto. Based on allocations and prioritizing set out by Toronto Public Health and the provincially-mandated Toronto Central Local Health Integration Network,


LTC residents are vaccinated by staff from their hospital partners, which were established earlier in the pandemic. UHN has 13 LTC partners. At lunchtime on Dec. 29, Shiran Isaacksz, Vice President Altum Health & UHN Connected Care, was tasked with leading the organization’s mobile vaccination rollout. With the first Moderna shipment scheduled to arrive the next day and the goal of starting shots in arms the day after that, his team had 48 hours to assemble all the key players at UHN and in the community to make it happen. It was Connected Care on full display – pulling together inter-disciplinary teams who each use their expertise to make a positive impact, collectively. It was about being able to pivot and scale quickly internally, while also working with community partners and city and provincial health authorities. These are the principles of UHN’s Integrated Care Program and what allowed the team to get mobile vaccination in the community up and running so quickly. Among the key contributors: • UHN Pharmacy, leading the way on the rollout of the Pfizer-BioNTech vaccine since mid-December, oversees Moderna distribution and delivery; • The Family Health Team at TWH, which in April proactively began swabbing residents and staff at many LTCs and has largely staffed the COVID Assessment Centre at TWH, does the vaccinations; • The UHN Long-Term Care Support Team, which has been providing ongoing assistance and Infection Prevention and Control (IPAC) expertise to LTCs and retirement homes since early in the pandemic, works with each of the homes to ensure they’re ready for the arrival of the mobile vaccine team; • The LTCs themselves obtain consents from residents, ensure there’s a place for vaccinations to happen and have staff on hand to help organize on-site needs, complete the neces-

Photo: Brian Hodges

Helen Lampi, (L), Director of Nursing at Castleview Wychwood Towers, welcomes back members of UHN’s Mobile Vaccine Team – flashing “V” for vaccine – last week as they prepare to administer second doses of Moderna’s COVID-19 vaccine. On Dec. 31, the team kicked off the vaccination drive at the home. sary documentation and monitor recipients for adverse reactions for 15 minutes; • Members of UHN Connected Care ensure the needs and experience of residents, staff and essential caregivers are prioritized. They also provide the critical backbone support, including education, training, and logistics, which ranges from clearly delineating who handles what tasks at each site and determining how many doses of vaccine are required, to ensuring data on who is vaccinated gets added to the provincial registry and making sure the team has food and water. At the outset, all teams were governed by two key principles: safety and speed. A mobile vaccination model was developed and at work in LTCs within 48 hours. Each evening, an Operations Team featuring representation from all UHN teams involved, met virtu-

ally to review that day’s events. Over the course of its first week of meeting, workflows were improved, the drawing of doses was refined to ensure no vaccine was wasted and overall efficiency of the process was polished. Collaborating with counterparts from across the health system, including family medicine teams from other hospitals – Humber River, Michael Garron, North York General, Scarborough Health Network, Sinai Health, Sunnybrook, Unity Health Toronto and Women’s College – brought different skills and strengths together to improve the vaccination model. “We want this approach to continue, to put down our hospital badges and work collaboratively with other endeavours, not just in an emergency. There are so many opportunities for us to come together for the benefit of our hospitals, and more importantly, H for the benefits of all patients.” ■

This article was provided by University Health Network. 38 HOSPITAL NEWS MARCH 2021

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INFECTION CONTROL 2021 The OMTU includes its own ambulance intake for patient offloading, an infection control isolation room, four staff stations, and other amenities. It is connected to the Civic Campus Emergency Department and ICU via an above-ground tunnel.

New unit adds forty hospital beds to help increase capacity, reduce wait times By Caitlin Renneson orty hospital beds. An impressively high “cathedral” ceiling. A bright, warm and organized space. In some ways, this new unit looks much like other inpatient units in the main building of The Ottawa Hospital, but it has something a little extra: an undeniable energy that comes from knowing you are part of something new.



The Offload Medicine Transition Unit (OMTU) is a new 40-bed temporary structure located at the Civic Campus of The Ottawa Hospital. Funded by the provincial government 40 HOSPITAL NEWS MARCH 2021

and constructed in just nine weeks, the OMTU will help expand hospital capacity, decrease ambulance offload times for paramedics and get patients into hospital beds faster once admitted. It welcomed its first patient on January 4.


The OMTU includes its own ambulance intake for patient offloading, an infection control isolation room, four staff stations, a staff lounge, washroom facilities and showers. It has proper air ventilation and is fully climate controlled. Each patient bay has oxygen and suction, a nurse call system, and emergency power. Like the main hospital,

the OMTU has modern medical technology, wi-fi for patients and wired internet connections for computers on site that are connected to EPIC, the hospital information system. Staff and patients can access the main hospital’s Emergency Department and Intensive Care Unit (ICU) through an aboveground tunnel. The staff at the OMTU include doctors, nurses, registered practical nurses, physiotherapists, social workers, orderlies and others that you might expect inside any other patient unit. Staff supporting the OMTU underwent simulation training for emergency code calls before the unit opened, just as they would have before opening any other new unit.


Although the focus was on maximizing safety and care, the patient experience was also a priority. Each patient bay is slightly bigger than what you would typically see in the emergency department. Stretchers are fitted with thick gel mattresses. There are hooks for coats and shelves in each bay for belongings. There is a dimmable light above the bed and a whiteboard on the wall to keep important information. “It was really impressive, how high the ceilings were, how everything came together in nine weeks,” says Kyle Gantner, Acting Clinical Manager for the OMTU.

“Patients seem to like the semi-open concept,” says Jeanne Millons, Acting Clinical Care Leader for the OMTU. “The rooms don’t have a roof over each of them, so there are things to look at if you want to be distracted.” Gantner and Millons each lay down in patient beds themselves before the unit was open to get a first-hand view of what it would be like for a patient.


The concept, design, layout, construction and ultimate operation of the OMTU was the result of impressive teamwork from many groups and individuals. Kathleen McGarragle is the Emergency Management Officer at The Ottawa Hospital and co-project manager for the unit. She and Dwight Breault, Senior Project Manager of Capital Projects, led the project on behalf of the hospital. They worked closely with Colliers, Infrastructure Ontario/The Ministry of Health, BLT Construction, and several design and consulting firms. Many hospital departments and teams offered their expertise and support as well. Hospital leadership, clin-


A corridor in the new OMTU ical teams, Emergency Management, Capital Projects, Facilities, Planning, Infection Prevention and Control, Care Environment Transportation,


Environmental Services, Materials Management, Nutrition and Food Services, IS/IT, Biomedical Engineering, Fusion, Parking Services, Protective

Services, the Safety Office, The University of Ottawa Skills and Simulation Centre and the Simulation Continued on page 42



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Forty hospital beds Continued from page 41 Patient Safety Program, the Cancer Program, Accessibility Services, Occupational Health and Wellness, the Communications Department and many others worked in concert to make sure everything came together. From a health-care standpoint, doctors, nurses, infection prevention and control experts, clinical care leaders, directors and others from the Emergency Department and inpatient units all had a hand in determining what the space would look like and how it would function. “The Ottawa Hospital really came together with different departments doing everything they could to help,” says McGarragle. “We went live on January 4, so the biggest push was over the holiday period. That means a lot of people worked extra hard to get it done.” Read adds, “It’s a great example of living our vision of providing worldclass care, exceptional service and compassion just as we would want for our loved ones. Everyone worked together to achieve a goal that would support our patients and our teams, especially during a very challenging time.”

A STRONG COMMUNITY PARTNERSHIP Another important element to the project’s success was the partnership between the hospital and the community. “Even though we knew that the OMTU would be a great benefit to the community overall, we recognized that constructing it would have an impact on the local community,” says Joanne Read, Executive Vice-President of Planning and Development for The Ottawa Hospital. “We wanted to establish open lines of communication throughout the project to make sure that the community had a voice and we could try to minimize any impact on them.” The project team also worked with hospital departments and services that would be impacted most by the construction, including the Academic Family Health Team and programs in Grimes Lodge.

CONSTRUCTED IN JUST NINE WEEKS, A NEW 40-BED TEMPORARY STRUCTURE AT THE OTTAWA HOSPITAL’S CIVIC CAMPUS WILL HELP INCREASE CAPACITY AND REDUCE AMBULANCE OFFLOAD TIMES. Kyle Gantner (left) and Jeanne Millons are part of a large team dedicated to providing world-class care to patients in the OMTU. Constant and open communications was a priority from the start and contributed to the project’s success. “My objective was to make sure that everyone that was supposed to be included was included,” says McGarragle. “If I needed to follow up with a group or team, I did, without fail, every time.”


Opening a new hospital unit is a special occasion, and it often comes with a sense of excitement among staff. That is especially true in this case because the staff were engaged in the design of the OMTU from the very beginning. “We were part of building something from the ground up,” says Milions. “From construction, to making decisions about how the room looks, to hiring and onboarding a whole new staff, it kind of feels like we are in this together in this new journey.” Gantner feels the same way.

“We got to start from the beginning. We get to build a team and work as a team as the OMTU evolves. I think, for me, that’s what makes the OMTU special. We get to set it up together and work together to make it a very good environment for both the patients and the staff.” And that sense of shared purpose has carried over into the culture in the unit. “We have a very positive team,: adds Gantner. Staff are very engaged. Its an environment open to change. We focus a lot on teamwork.” A culture of constant improvement Even though the OMTU has been open for a little more than a month, the staff have settled into a groove. Still, staff are continuously looking for opportunities to improve how they deliver care. “It’s evolving on a daily basis,” says Gantner. “We’ve evolved lots of things. From the layout of supplies and the types of supplies we use, to how nurses and registered practical nurses work together to provide safe patient

care. We lean on staff a lot to figure out what works best for them. We let them guide the evolution and we help facilitate change to make their space theirs.”


The benefits to the community are many. Its 40 beds help free up beds in the Emergency Department and on inpatient floors for patients who need that specialty care. The OMTU will help to ensure that our community gets the care that they want and they deserve” says Millons. “It’s a success story for sure.” And it wouldn’t have happened without an incredible amount of support. “Thank you to everyone, the community, the staff, the patients, the project managers, everyone involved in planning and construction,” says Read. “It is safe, it is clean, it is warm, it is comfortable. We hope you never need to visit the OMTU yourself or with a loved one, but if you do, know H that it is there for you.” ■

Caitlin Renneson is the Publications Officer at The Ottawa Hospital. 42 HOSPITAL NEWS MARCH 2021



Exploring the evolving world of digital health through the pandemic and beyond By Daniel Martz, Vice President, Virtual Care, TELUS Health he World Health Organization (WHO) global strategy for digital health acknowledges the potential for technology to accelerate human progress, predicting these solutions will help ensure more people enjoy better health and well-being. Specifically noting applications that enable virtual care, remote patient monitoring, and data exchange across the healthcare ecosystem, the strategy suggests these technologies can improve experiences within the care continuum and drive enhanced health outcomes. While the use of digitally-enabled healthcare tools has increased steadily in the last few years, widespread adoption has grown exponentially since the onset of COVID-19. With an overburdened healthcare system and growing concern of contracting the virus in medical settings, government and healthcare leaders turned to technology to help bridge gaps in care access and ensure Canadians were supported through these challenging times. A study by ICES, Ontario’s leading health and social data research organization, showed that in the first few months of the pandemic, visits to primary care clinics declined by 79 per cent while virtual visits, per 1,000 individuals per day, rose by a staggering 5,600 per cent. This transformation was made possible by innovations that connected Canadians with care teams from the comfort and safety of their own homes. Whether through functionalities integrated into physicians’ electronic medical records (EMRs) or mobile applications for those without access to a family physician or who have access to health and wellness services through their insurance or benefits provider, healthcare professionals across the country began offering virtual appointments with the support of these technological ad-



THE INNOVATIONS WE HAVE SEEN EMERGE HAVE NOT ONLY ADDRESSED THE SIGNIFICANT CHALLENGES POSED BY COVID-19, BUT HAVE ALSO POSITIVELY IMPACTED THE SUSTAINABILITY OF OUR HEALTH SYSTEM. vancements. This significantly eased the burden on hospitals, enabling them to focus on supporting Canadians requiring urgent care. Virtual care also presents a modern approach to triaging and monitoring. Technology is being used to virtually triage potential COVID-19 cases before a patient arrives at the hospital. Other solutions, such as TELUS’ Home Health Monitoring (HHM), are being used to track the condition of hundreds of patients at once as they recover from COVID-19 at home. This strategy helps open capacity for more critical cases, reducing pressure on hospitals. The HHM solution has since been used to remotely monitor people recovering from organ transplants and those with chronic conditions, keeping them out of hospitals where risk of exposure is greater.

Digital health solutions have also played a critical role in giving Canadians access to their own health information. Governments in Alberta and Saskatchewan have provided residents with personal health records allowing them to view and track their own medical information. These records have enabled quick access to COVID-19 test results, helping to reduce anxiety associated with waiting days for a diagnosis. The innovations we have seen emerge have not only addressed the significant challenges posed by COVID-19, but have also positively impacted the sustainability of our health system. What do Canadians have to say about the future of digital health? According to them, digital health is here to stay. Research from Canada

Health Infoway suggests 84 per cent of Canadians would use technology to help manage their health while a 2020 Canadian Medical Association poll highlighted that Canadians who connected with a physician virtually reported a 91 per cent satisfaction rate. Public health systems are also taking important steps to prioritize digital health. Alberta was the first to make virtual care physician billing fee codes permanent, enabling the ongoing delivery of virtual care across the province. Meanwhile, the federal government has made significant investments to expand virtual care in British Columbia and Prince Edward Island, supporting the longer-term adoption of high-quality and safe virtual healthcare options. There is a bright future for digital health in Canada. Already virtual care has expanded to include services by allied healthcare professionals such as physiotherapists, nutritionists and mental health counsellors. With the introduction of new services such as online pharmacies, a fully integrated, end-to-end virtual care experience that addresses multiple aspects of care is not too far in the future. And the roll-out of 5G technology holds great promise in making this complete experience seamless, enhancing connectivity across the country while enabling new applications. As our healthcare landscape continues to evolve, we must remember the importance of collaboration and interoperability. If we work together to take our siloed platforms and unify them to enable efficient communication across physician EMRs, pharmacy management systems, virtual care solutions and insurance claims processes, we can take a step closer to connecting all aspects of health, supporting the continuity of care for Canadians and ultimately driving better health outcomes.

16th Annual Hospital News




Please submit your nursing hero stories by April 9th and make sure that your entry contains the following information:

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An ethical obligation to prioritize people with intellectual disabilities for the COVID-19 vaccine By Andria Bianchi, Ana Luisa Santo and Yona Lunsky n December 9th, 2020, a palpable sense of relief was experienced by many healthcare providers and members of the public upon learning that Health Canada approved its first COVID-19 vaccine, co-developed by Pfizer and BIoNTech. The Moderna vaccine was approved shortly thereafter, and other vaccines are currently in the works. Although Canada secured a substantial number of vaccines, it will take time to inoculate everyone who wants it. Consequently, and as many of us know, it is necessary to prioritize people during the vaccine rollout. Canada’s National Advisory Committee on Immunization (NACI) makes recommendations about the use of vaccines for humans. In relation to COVID-19, the Committee has argued that certain groups ought to be prioritized based on their level of vulnerability, i.e., the likelihood of becoming infected and harmed by the disease. According to NACI, the first group to be prioritized (“Stage 1”) for the COVID-19 vaccine includes: (1) people in congregate living settings that care for seniors (e.g., residents and staff working in long-term care); (2) individuals over 70; (3) health care workers; and (4) Indigenous communities. The second group (“Stage 2”) includes: adults from Indigenous communities who are not yet inoculated; residents and staff of other congregate settings (e.g., homeless shelters; group homes); first responders; adults between 60-69; adults from racialized and marginalized communities; frontline essential workers who cannot work virtually; and primary caregivers for people at high-risk of COVID due to advanced age. In order to help guide ethical decision-making regarding the immunization rollout, NACI suggests that “efforts should be made to increase access to immunization services to reduce health inequities without further stigmatization or discrimination, and



to engage systemically marginalized populations…” The purpose of NACI’s recommendations make sense insofar as they are meant to ensure that the most vulnerable populations get inoculated. When thinking about equity and ensuring that marginalized populations are serviced, however, it is concerning that people with intellectual disabilities have not been specifically mentioned as deserving of prioritization (ideally as part of Stage 1, though it is now too late). As cited in a recent report, adults with intellectual disabilities are more likely to contract and die from COVID-19. Although there has been minimal research published about COVID-19 and intellectual disabilities in Canada, Public Health England completed a review citing the number of COVID deaths among people with intellectual disabilities (referred to as “learning disabilities” in the UK). Based on information attained between February 2020 and June 5, adults with intellectual disabilities were deemed 2.3 times more likely than the general population to die from or with COVID. In response to the likelihood of under-notification, however, it was

determined that people with intellectual disabilities may actually be 3.6 times more likely to incur and die from the disease, perhaps especially those living in congregate settings. Importantly, the average age at death was much younger than what is seen in the general population. A more recent study including data up to November 20, 2020 concluded that “[p]eople with a [intellectual] disability made up six in 100 (5.8%) of all deaths involving the coronavirus… (2,955 of 50,888 deaths). For comparison, people with a [intellectual] disability made up 1.2 per cent of the study population, therefore suggesting that people with a [intellectual] disability have been disproportionately impacted by the COVID-19 pandemic.” The above studies focus on people with various intellectual disabilities, however, it ought to be noted that people with Down syndrome specifically are 10 times more likely to die as a consequence of COVID and more likely to be hospitalized at younger ages. As per one retrospective analysis, the median age of hospitalized COVID-19 patients with Down syndrome is 54, whereas the rest of the

population is 66. This difference in age is concerning. According to NACI, people between the ages of 60-69 are one of the most vulnerable groups who ought to be a part of Stage 2 for the COVID-19 vaccine. It seems to be the case, however, that people who are younger than 60 and who have Down syndrome, and other types of intellectual disabilities, may experience similar – if not worse – consequences from COVID. Not only are death rates among those with intellectual disabilities higher than the general population, but the negative impact of COVID is seemingly amplified. Many people with intellectual disabilities may be unable to fully comprehend the rationale behind our new and ever-changing social norms and policies (e.g., isolating, maintaining distance, wearing masks, etc.). And because some people with intellectual disabilities may be unable to effectively and consistently comply with current health measures, it seems plausible that even more restrictive measures may be implemented. These more restrictive measures have negative consequences of their own in that people with intellectual disabilities

ETHICS may be even more isolated than others. Furthermore, people with intellectual disabilities require support from others, where the amount and type of support will vary depending on the severity of the disability; this makes it such that it will either be impossible for this population to physically distance or possible but with significant impact on quality of life. In addition to the above restrictive measures, the inability to participate in structured activities (e.g., to participate in work, skill based, and recreational activities) has led to an increase of mental health challenges and/or corresponding behaviours amongst people with intellectual disabilities; this is highlighted in the results of a needs assessment survey that was completed by the Research and Education working group of the Sector Pandemic Planning Initiative (SPPI) in Toronto, Ontario. The purpose of the survey was to explore the effects of COVID-19 on people with developmental disabilities and their families.

Amongst the 1083 responses received, “[a]pproximately half of respondents reported increased anxiety, depression, and behavioural issues.” Over half of respondents also flagged that they could not access supports. For many adults with intellectual disabilities, attending day programs, doing activities with peers, and participating in work may significantly improve their mental health, decrease behavioural challenges, and improve quality of life. While several organizations now offer virtual programming, significant limitations are encountered by people with intellectual disabilities due to factors related to their disabilities, such as being unable to afford necessary technology, effectively utilize the technology because of cognitive, physical, and/or language barriers, and/or to focus on the relevant activity when it occurs virtually. Finally, and as a direct consequence of the above, people caring for those with intellectual disabilities (both paid and unpaid) are bearing substantial

stress and pressure. For example, although working from home can bring challenges for many, additional challenges are experienced by families caring for individuals with intellectual disabilities and trying to work (in addition to having other responsibilities and commitments). While emergency childcare has been available at some points for parents working from home who have young children, family caregivers who are working from home and supporting adult loved ones with intellectual disabilities have not been able to access this same level of respite. Ultimately, the physical and mental health of people with intellectual disabilities and their caregivers continues to be negatively and disproportionately influenced by the COVID-19 pandemic. While these negative consequences are concerning in and of themselves, it seems that many of the challenges and related outcomes could be mitigated by prioritizing this particular population for the vaccine. So, why aren’t we doing it? Failing to explicitly state that

people with intellectual disabilities need to be prioritized is causing a measurable and detrimental effect. As mentioned in a previous column, equity “suggests that a person’s individual vulnerabilities and life circumstances are relevant to determining the most ethically defensible act,” tand NACI recommends making an effort to reduce inequities as part of the vaccine rollout. Although people with intellectual disabilities may be included in the vaccine rollout as a part of other clinical groups, the lack of clarity regarding whether this is, in fact, the case, may cause additional anxiety amongst a group that is already anxious and distressed. Ultimately, based on the substantial vulnerabilities that are present for persons with intellectual disabilities, in addition to life circumstances during the pandemic, it seems evident that they ought to be specifically prioritized to receive the vaccine. We have seen prioritization in other jurisdictions, and it is time to H do so here. ■

Andria Bianchi, PhD, is a Toronto-based bioethicist and an Assistant Professor (status-only) at the Dalla Lana School of Public Health, University of Toronto, Ana Luisa Santo, MA, BCBA, is a Senior Behaviour Therapist at Surrey Place and Yona Lunsky PhD CPsych, directs the Health Care Access and Developmental Disabilities (H-CARDD) Program at the Azrieli Adult Neurodevelopmental Centre, CAMH.




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Nursing home staff responses to the pandemic reveal resilience and shortcomings By Patrick Lejtenyi he ongoing health disaster of the past 12 months has exposed the crises facing nursing homes in Canada and the United States and the struggles of the staff working in them. Writing in the Journal of Comparative Policy Analysis: Research and Practice, PhD student Daniel Dickson, his supervisor Patrik Marier, professor of political science, and co-author Robert Henry Cox of the University of South Carolina perform a comparative analysis of those workers’ experiences. In it, they look at Quebec (including those at government-run CHSLDs), British Columbia, Washington State and Ohio by reviewing 336 articles in six newspapers published between late-February and mid-June 2020.



“We wanted to see how the pandemic affected the discretion of frontline workers,” Dickson says. “Their professional knowledge, their experience and their abilities make them really valuable assets.” Even if, the researchers note, they are hardly treated as such. For years, care workers – 85 per cent of whom are women and 50 per cent of whom are born outside the country, accord-

ing to a recent Canadian study – coped with low levels of pay, status and likelihood of advancement. Now, they write, care workers are also faced with “an existential threat to themselves or their immediate families” in the form of the novel coronavirus. To analyze how care workers responded to this added job stressor, the researchers adapted a trusted organizational studies model first developed by Albert Hirschman in 1970. They could take up a pattern of resistance, meaning increased ab-

senteeism or refusing to work without added compensatory pay; they could try innovation, in which they communicate their concerns to management and create new protocols better suited to a new, more dangerous reality; or they could apply improvisation, where frustrated employees stay out of a sense of duty and try to make do with what they have. “We expected a lot of resistance, that frontline workers would be looking for ways to diverge from policy intent or just quit their jobs,” Dickson shares. “The ideal case would be more innovation, where the experiences of frontline workers would be privileged and a lot of weight would be given to their knowledge. But we know that they are not afforded that position in the policy process; they are not given this kind of esteem or support.”

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Resistance was widespread in Quebec. The research sample of 336 newspaper articles contained 45 that explicitly mentioned resistance, with 78 per cent of those originating in Quebec. Absenteeism was especially high in Montreal, where nursing and long-term care homes were hit early and hard. The province was also the leader when it came to mentions of improvisation. A total of 77 articles discussed some form of improvisation, with 79 per cent originating in Quebec. This included articles on the government recruiting health professionals from all fields and calling in the army as well as care workers using coffee filters beneath their handsewn face coverings due to a shortage of N95 masks. Innovation was noted in British Columbia, where staff were able to adhere to protocols by adopting Zoom meetings for virtual patient visits and “door-

PhD student Daniel Dickson compared how US and Canadian workers handled outbreaks in long-term care facilities. way bingo,” and in the US, where staff stepped in for family unable to see their dying loved ones. These responses, the authors note, stemmed most from workers’ experience and expertise.

The analysis exposed some serious fault lines in long-term care regimes north and south of the border, Marier adds. “We talk about how great Canada’s health-care sys-

Patrick Lejtenyi is an Advisor, Public Affairs at Concordia University.

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tem is vis-à-vis that of the United States, especially in terms of universal accessibility, but we are not that different when it comes to longH term care.” ■


The government’s response to the crisis in long-term care must include

robust data-driven change By Carole Estabrooks ore than 19,000 people in Canada have died from COVID-19 – more than 17,000 of them aged over 60 years. The majority of those deaths occurred in long-term care homes. This crisis continues now, even after governments and operators have put in place emergency strategies and, in some jurisdictions, creative solutions to address staff shortages. For example, offering to pay relatives to provide care, creating new support roles with free training and providing salary topups. This response, however, is years late, and piecemeal in its approach. In June, the Royal Society of Canada released a policy briefing by the Working Group on Long-Term Care which outlined nine recommendations that would go a long way to “not just fix the current communicable disease crisis, but fix the sector that enabled the crisis to wreak such avoidable and tragic havoc.” The federal government is moving forward, working with the provinces and territories, to forge national standards for long-term care. The creation of the Safe Long Term Care fund will provide significant funding to protect people in long term care. However, these initiatives will not be sufficient to support sustained improvements for residents unless we address two foundational elements of any Learning Health System: comprehensive, quality data, and an ecosystem supporting acting on those data by managers who run the system and the individual LTC homes. These two elements must occur in tandem in an ongoing cycle of learning and improvement. The long-term care crisis, in part, is a data crisis. Currently the only systematic, routinely collected data, in most, but not all jurisdictions, focus on quality of care. This is essential, but if it were


Carole Estabrooks

THE LONG-TERM CARE CRISIS, IN PART, IS A DATA CRISIS. CURRENTLY THE ONLY SYSTEMATIC, ROUTINELY COLLECTED DATA, IN MOST, BUT NOT ALL JURISDICTIONS, FOCUS ON QUALITY OF CARE. tenough, long-term care would not be in the state it is and Canadians would not be trying to understand why we are the poorest performing country globally in the pandemic’s impact on long term care. Data must be comprehensive and reliable. It must be collected in all Canadian jurisdictions. It must be reported with transparency. It must be acted upon. In particular, we must fill four major data gaps. First, we require high quality dementia specific quality of life data – data that will tell us how older adults with dementia (the majority popula-

tion in long term care) subjectively experience their lives. Second, we require comprehensive data on our essential direct care workforce. These data include basic demographic information such as race and ethnicity, data on health, well-being and job experiences – essential for workforce planning and for targeting improvement efforts to ensure that the workforce has good work life quality. Third, data on family and other unpaid caregivers – increasingly known as essential care partners – experiences must be available. Fourth, we require

data on the work environment as we know that it strongly affects staff, residents and family. The data, which must be linkable, are a minimum standard for effectively managing the system. But, if we do not support an ecosystem for acting on data-based findings and trends, if we do not make the findings and trends available to managers at all levels of the system in a manner that is accessible to them, if there are no supports for them on how to use data for change and improvement – data will do no more than appease our need to be seen to be doing something. It will not be adequate if all we accomplish are rich databases for scientists to track. We must have a system that supports data-based action for real change to occur at the point of care. Getting the data, no matter how challenging (it will be) will be the easy part of this equation. The Royal Society report recommends that federal support of the long-term care sector must be tied to requirements for data collection in all appropriate spheres that are needed to effectively manage and support longterm care homes and their residents and staff. Quality data provided in a user-friendly manner and support to act, will enable managers to develop goals and implement action plans in a process of plan, do, study, act and evaluate cycles of learning and improvement. Within a group of nearly 100 LTC homes that our pan Canadian, longitudinal program, Translating Research in Elder Care has followed nearly 15 years now, we have developed the foundation for such a system with positive results for managers, care aides, other direct care staff – and residents. It is challenging work but it is achievable. When a supportive system based on good data works for the managers and staff, the residents have better care, the long-term care system is healthier H – and we all do better. ■

Carole Estabrooks is Scientific Director of Translating Research in Elder Care and Professor in the Faculty of Nursing at the University of Alberta. 50 HOSPITAL NEWS MARCH 2021

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collaboration was important then but

Critical now

Professional Inter-

By Ereny Botross, Amy Botross, and Certina Ho roviding patient care can be challenging, especially when multiple health care professionals (HCPs) are involved in the patient’s circle of care. Maintaining continuous interprofessional collaboration and proper communication thus become pivotal to ensure optimal patient care and safety.



According to the World Health Organization (WHO) Framework for Action on Interprofessional Education and Collaborative Practice ( framework_action/en/), “collaborative practice happens when multiple health workers from different professional background work together with patients, families, carers and communities to deliver the highest quality of care”. Hence, interprofessional collaboration can be viewed as a “jigsaw puzzle” (Figure 1) where multiple healthcare team members contribute different “puzzle” pieces to ensure proper assembly of the “end-product” (i.e. holistic patient-centered care).


I. Gather a comprehensive medical and medication history The first step in providing patient care is to gather a thorough medical history and relevant patient information. This step is crucial to establish efficacy and safety of the proposed treatment plan, such as ensuring no contraindications, no drug-drug inter-

actions, and no potential allergic reactions, etc. However, it is possible that some information may still be missed when the patient is seen by multiple HCPs (e.g. a primary care physician, a pharmacist, a nurse, a dietitian, etc.). Through interprofessional collaboration and effective communication, these information gaps can be prevented, thus providing each of the health care team members (involved in the patient’s circle of care) with a comprehensive medical history, a best possible medication history, and all the relevant information necessary for safe and effective care. II. Mitigate and prevent errors Similar to the Swiss Cheese ( articles/PMC1117770/) model, the different HCPs can serve as different defense layers to intercept any potential errors before reaching the patient and mitigate their harm or effects. To optimize the various Swiss Cheese layers, interprofessional collaboration needs to be in place to enable effective and efficient communication among the different HCPs, so that potential treatment or therapy issues can be identified, addressed, and resolved in a timely manner. For example, when pharmacists conduct medication reviews with patients, drug therapy problems and other health related issues may be identified; these can then be communicated with the patient’s primary and corresponding health care providers who will then work collaboratively to resolve any patient related concerns and seek treatment alternatives.



Interprofessional collaboration is similar to a jigsaw puzzle

COLLABORATIVE PRACTICE HAPPENS WHEN MULTIPLE HEALTH WORKERS FROM DIFFERENT PROFESSIONAL BACKGROUND WORK TOGETHER WITH PATIENTS, FAMILIES, CARERS AND COMMUNITIES TO DELIVER THE HIGHEST QUALITY OF CARE III. Ensure proper monitoring and follow-up with patient engagement Monitoring and follow-up are generally the last step in providing patient care to ensure the efficacy and safety endpoints of the treatment plan are being met. Unfortunately, this step can sometimes be compromised when one HCP assumes that it is being taken care of by another provider in the patient’s care team. Thus, it is always important to engage the patient who is in the centre of care and can help facilitate interprofessional collaboration with an ultimate goal of treatment adherence, efficacy, and safety.


Though always important, interprofessional collaboration is now more critical than ever. The current pandemic has made it challenging for a lot of patients, particularly those who are

not tech savvy, to access appropriate health care. With some HCPs more readily available and easily accessible than others, it becomes critical that the different HCPs (involved in the patient’s circle of care) collaborate and communicate with each other to ensure patients are getting the care they need. For example, a medication review can be initiated by a pharmacist or requested by a patient at a community pharmacy. Through a comprehensive medication review, the pharmacist can then communicate drug therapy problems (if any) and work with the rest of the patient’s health care team to identify proper treatment options or solutions. This will not only ensure continuity of care, but may also help prevent potential hospitalizations and emergency visits, and perhaps reduce the number of times that patients, especially the highrisk populations, would have to leave their homes to seek medical attention H amidst the pandemic. ■

Ereny Botross and Amy Botross are PharmD Students at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and Leslie Dan Faculty of Pharmacy, University of Toronto. 52 HOSPITAL NEWS MARCH 2021


Human vs artificial intelligence:

How well does AI detect lung cancer? By Eftyhia Helis hat if a computer was better than a trained clinician for making an accurate disease diagnosis? And, what if it could detect a health issue before it has even fully developed? This may be the case in the field of lung cancer diagnosis. According to a November 18, 2020 article by Elizabeth Svoboda, published in Nature, computers that were trained to recognize and interpret images from medical scans were as good and, in some cases, better than doctors for detecting lung cancer from patient medical imaging information. The detection was reported to be accurate even when the abnormal patterns on the scans were in such early stages that the human eye could have easily missed them. Lung cancer affects millions of people worldwide. According to the Canadian Cancer Society, lung cancer is the most commonly diagnosed cancer in Canada and is the leading cause of cancer death for both men and women. However, due to non-specific symptoms in the early stages of the disease, in many cases a diagnosis for lung cancer comes too late in the progression of the illness, thus making it difficult to successfully provide life-saving treatments. Early screening, especially for at-risk individuals (e.g., heavy smokers, people with a family history of lung cancer, and people who are exposed to certain chemicals in the workplace), and an accurate diagnosis are critical for reducing the risk of dying from lung cancer. Low-dose computed tomography (also called low-dose CT scan) is the recommended screening procedure for lung cancer, especially for adults who have no symptoms but are at high risk for developing the disease. The screening aims to identify any abnormal growth on the lung and assess whether it is benign (non-cancerous) or malignant (cancerous). This evaluation is usually done by a radiologist


who will assess whether cancer has developed. An accurate assessment is crucial for deciding on next steps for the treatment plan of the patient, such as biopsy or surgery, but it is also important for avoiding any unnecessary procedures. In the case of lung cancer, accurate assessment can be challenging, leading to a high number of wrong diagnoses. Artificial intelligence (AI), which is based on the concept of developing and training computer systems to perform tasks that would require human intelligence, is being considered as a tool to support accurate diagnoses. Canadian decision-makers are increasingly interested in the use of AI in the field of medical imaging. According to a recent pan-Canadian survey conducted by CADTH, AI is being used in at least 40 imaging departments across Canada (for both clinical and research purposes), with most of that use being with CT. In these imaging departments, AI is used not only for reading and interpreting images but also for improving image quality (image reconstruction) and for lowering radiation dose to manage radiation safety from exposure to CT. But what does the evidence say for using AI in lung cancer diagnosis? CADTH reviewed available evidence from seven studies that reported on

the accuracy of AI for diagnosing lung malignancies compared with diagnosis based on human observation (i.e., diagnosis made by radiologists or other clinicians). In the identified studies, AI algorithms were used to read CT scans to classify lung nodules as either benign or malignant. While the studies reported somewhat mixed results, there is evidence that AI models might be a promising support for improving accurate diagnosis in the field of lung cancer. Of the seven studies CADTH reviewed, four studies reported that AI models were more accurate at classifying lung nodules when compared with radiologists (two of these studies confirmed the difference in accuracy with a statistical test as well), while three studies found that AI models were either comparable or less accurate than human observers. In most studies that reported improved diagnostic accuracy by the AI algorithm, the authors noted that when compared with human observers, the AI models were more likely to correctly identify malignancies in individuals with cancerous nodules and were better at ruling out those nodules that were not cancerous. The mixed findings reported in the reviewed studies may reflect the variability in the AI models that were evaluated in the studies. And, despite

these promising trends, it may be premature to draw conclusions about using AI for lung nodule classification in clinical practice. More studies of high methodological quality and more real-world testing would help us understand how AI could be used for lung cancer diagnosis. In addition, there are several aspects of AI use – including privacy and safety of patient data, how AI fits in the current clinical routine, and what happens as these AI systems evolve rapidly – that need to be considered before the technology is fully adopted in clinical practice. The hope is that AI will be a valuable assistant to doctors and support improved treatment and survival outcomes among diagnosed patients. You can find the CADTH review described in this article at cadth. ca/artificial-intelligence-classification-lung-nodules-review-clinical-utility-diagnostic-accuracy-cost. If you’re interested in learning more about CADTH’s survey of medical imaging capacity in Canada – the Canadian Medical Imaging Inventory – visit, and for the latest evidence on oncology, visit oncology. If you’d like to learn more about CADTH, visit, follow us on Twitter @CADTH_ACMTS, or speak to a Liaison Officer in your H region: ■

Eftyhia Helis is a knowledge mobilization officer at CADTH.



Unity Health Toronto’s new Energy Team dedicated to reducing energy consumption By Selma Al-Samarrai ospitals have massive environmental footprints. It takes a lot of electricity for the 24/7 care required in acute care, emergency and long-term care residences. To tackle this impact, Katelyn Poyntz, Director, Project Engineering & Energy Engineering and Plant Services, Unity Health Toronto, created the Energy Team with the mission of finding ways to reduce energy consumption across the network’s three sites. The Energy Team has annual energy savings targets, and is made up of two Energy Project Managers, Emily Huang and Shailesh Abhang, and an Energy and Sustainability Project Assistant. They monitor the network’s energy usage, identify energy savings opportunities, and work with the rest of the Project Engineering team to implement the energy savings projects.


The Project Engineering team. From L to R, top to bottom: Rebecca Skolud, Senior Project Engineer; Emily Huang, Energy Project Manager; Tharshan Kamaleswaran, Senior Project Engineer; Katelyn Poyntz, Director, Project Engineering & Energy Engineering and Plant Services; Shailesh Abhang, Energy Project Manager; Fred Kane, Senior Project Engineer; Sean Ruel, Engineering Project Assistant; Sobini Ragunathan, Project Engineer; Dilroz Rana, Energy and Sustainability Coordinator (Sept. 2020) Huang and Abhang are also Certified Energy Managers.

“The Energy Team identifies energy opportunities and then once there’s

an asset to replace, the Project Engineering team gets involved. There’s a real synergy between the two teams,” explains Poyntz. The team has set out to retrofit the network with LED lighting over the next two years. This is expected to save $440,000 annually in electricity costs. The Energy Team also found that too many staff members were leaving their computers on at the end of the work day, which led to a network-wide Turn Off Your Computer Campaign. Because of this campaign, the network achieved $13,000 in annual savings, enough energy to power eight homes for a year. “It is incredibly rewarding to work with staff across the network who genuinely care about making these changes in order to improve energy efficiency by adopting best practices and implementing new technologies,” says Huang. Continued on page 55

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Green Team

makes health care more sustainable anada’s health care system is responsible for 4.6 per cent of the country’s pollutant emissions, both directly from healthcare facilities and vehicles, and indirectly through buying emission-intensive goods and services. This was one of the factors that compelled a group of staff and physicians at Unity Health Toronto’s St. Michael’s Academic Family Health Team (FHT) to create a Green Team. Their goal was to make their practice more environmentally friendly. This started as a local initiative in the Sumac Creek Health Centre clinic about a year and a half ago, and is now expanding into the remaining FHT clinics. Their first project focused on implementing a new recycling process. Within a few months, the Green Team had ordered recycling bins, placed them in high-traffic areas, and confirmed the pick-up process with Environmental Services staff. “With the global movement around environmental sustainability, there was an increased awareness of our impact within the FHT clinics, and a lot of our team members were already really engaged on this topic,” says Sarah Nestico, Clinical Nurse Specialist, Sumac clinic. A recent and very impactful sustainability change was the elimination

of exam table paper in patient rooms in two family health clinics. This decision was made easier by the pandemic because after every patient visit, all furniture including the patient bed had to be completely wiped down, which eliminated the need for the exam paper. Another change the Green Team successfully implemented was clarifying when to use the biohazard waste bins, which collect heavily soiled items that then need to be incinerated. They clearly distinguished what goes into the biohazard waste bins, and this helped significantly reduce what staff put in them. The Green Team also organized education seminars on how to implement certain sustainability practices, specifically at the Sumac clinic. “A big priority for the Green Team was just providing information,” says Julia Lee, Interim Patient and Community Engagement Specialist. “Often, unsustainable practice comes from misinformation, so education becomes a key tool in creating change.” The education covers a wide range of sustainability practices, including behavioural changes such as encouraging staff to bring in reusable containers, utensils and cups, and general sustainability practices such as turning off computers and office lights at the end of the day and minimizing printing. “I think part of the reason the Green Team initiatives have been so

Continued from page54 Both Energy Managers recently submitted their final energy report for the annual SaveOnEnergy Energy Manager Program. A review of the application by Independent Electricity System Operator (IESO) confirmed that 1,670,000 kWh in electricity savings was accrued for the fiscal year of 2019-2020, which is enough to power 186 homes for a year. Not only is this a great mile-

stone for the network’s Energy Managers, but also a source of additional funding for the Energy Team that they can allocate to new projects and initiatives. “Environmental sustainability and energy conservation are the need of the hour. I’m really proud to be an energy manager for a massive health network that prioritizes greening in health H care,” says Abhang. ■

By Selma Al-Samarrai



Selma Al-Samarrai is a communications adviser at Unity Health Toronto.

Sarah Nestico (left) and Ann Rodrigues are two members of the Green Team at St. Michael’s Family Health Team. (Photo: Yuri Markarov, Unity Health Toronto) ent processes and angles that were all taken into consideration. At the end of the day, we’re all interested in being more sustainable to protect H our environment. ■

successful is because there was a very intentional interprofessional lens on it that included physicians, nurses, clinical and administrative staff,” Lee adds. “There were many differ-

Selma Al-Samarrai is a communications adviser at Unity Health Toronto.


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