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A year of rebuilding at ORNGE

‘Tumour biobank’ brings breast cancer discoveries to the bedside more quickly




Canada's Health Care Newspaper

Nuring Pulse .......................................25

Issues, trends and treatment of diseases specific to men and women including perinatal care and prostate health. A retrospective look at advancements and trends in health care and delivery in 2013.

Caregiving ...........................................26 Evidence Matters ...............................28

DEC 2013 | VOLUME 26 ISSUE 12 |

From the CEO's desk..........................29

How healthy is our health care system? By John Wright and Jeremy Veillard ccess to doctors and treatment. Safe, quality care. Value for money. Better outcomes. These are the health system issues that Canadians say matter most to them, time and time again. These and fairness – making sure those who need quality care can get it, no matter their income. Meanwhile, organizations across Canada are making concerted efforts to collect data on a wide range of subjects; access, quality of care, return on investment, and patient outcomes are only some of what they’re encompassing. It’s a valuable exercise for people who work in the system, as they can use the data to measure, evaluate and improve performance‌ and patient care. What’s been missing, however, is something that distills comprehensive data specifically for the public. A resource that presents meaningful information concisely to give Canadians a snapshot on the health of the health system.




Continued on page 12



















CANADA Higher than average H



LLower than average The average cost of a hospital stay across the country. Higher cost means a hospital or region spends relatively more per patient stay for a similar patient.







In Brief New Red Cross app helps users provide life-saving first aid Nearly 40 per cent of Canadians say they have been in an emergency situation where they have had to perform first aid, but few believe they could help someone suffering a heart attack. November was CPR Month, an annual campaign to promote the importance of CPR as a life-saving skill. The Red Cross urges Canadians to take a course and download the free First Aid App to keep their lifesaving skills up to date. "Downloading the free Canadian Red Cross First Aid App puts critical knowledge in your hands, and helps Canadians provide life-saving assistance any time, any where," says Don Marentette, national manager of first aid programs. "Only 15 per cent of Canadians say they could confidently help someone suffering from a heart attack, but it takes only half a day to learn the necessary skills to save a life." Available for Apple and Android mobile devices, the app helps users maintain their first aid skills and respond to everyday emergencies. Users get instant access to videos, interactive quizzes and simple step-by-step advice to help them maintain their life-savH ing skills and respond when needed. ■

CAMH and Assurex Health launch joint venture to advance personalized medicine

The Centre for Addiction and Mental Health (CAMH), Canada's leading hospital for mental health, and Assurex Health, a global leader in personalized medicine, have signed an agreement for a joint venture to bring the benefits of this treatment approach to more Canadians. The personalized approach helps to match the right medication at the right dose for each patient, based on their genetic makeup. Using Assurex Health's GeneSight panel, physicians can easily see which psychiatric medications are likely to be effective for each patient and which ones are not, often avoiding treatment failure and side effects. In Canadian clinical trials, researchers are aiming to conduct genetic tests on 20,000 individuals. Genetic testing is currently available through CAMH's IMPACT study ( In Canada, the GeneSight panel will be enriched with new CAMH-discovered genetic markers. These may include markers to predict which individuals will experience weight gain after taking anti-psychotic medications. Weight gain is a serious side-effect H for a substantial number of patients. ■


Harper Government strengthens health research in Alberta Federal Health Minister Rona Ambrose and Alberta Health Minister Fred Horne announced the launch of the Alberta SUPPORT Unit for patient-oriented research. SUPPORT (Support for People and Patient-Oriented Research and Trials) Units are provincial or regional centres designed to support those engaged in patient-oriented research. They are locally accessible, multi-disciplinary clusters of research resources, policy knowledge, and patient perspective. They provide the necessary expertise to pursue patientoriented research and help lead reforms

in response to locally-driven health care needs. All provinces and territories are working collaboratively on this pan-Canadian initiative, with SUPPORT Units to be established in regions throughout the country. "Patient-oriented research is about bringing research evidence to the point of care," said Dr. Alain Beaudet, President of CIHR. "The SUPPORT Units will create the infrastructure that will allow patient-oriented research to thrive throughout the country. On behalf of Canada's health research community, I

commend the provinces and territories for working collaboratively to improve health outcomes for all Canadians." The SUPPORT Units are part of Canada's Strategy for Patient-Oriented Research (SPOR). SPOR is a national coalition of federal, provincial and territorial partners (patient advocates, provincial health authorities, academic health centres, charities, philanthropic organizations, pharmaceutical sector) dedicated to the integration of research into care – the right patient receives the right treatment H at the right time. ■

Report on decade of health reform finds governments’ status quo approach is failing Canadians The Health Council of Canada released, Better health, better care, better value for all, showing that a decade of health care reform in Canada has produced disappointing results for taxpayers and patients alike. While the 2003 and 2004 health accords were heralded with much promise by governments, as the decade progressed a lack of focus on transforming the system leaves us where we are today. The report provides some lessons learned and outlines a way forward so as not to repeat the past record. The report finds that, with some exceptions, changes to our health care system have not kept pace with the evolving needs of Canadians. Progress on wait times for key procedures has stalled. Primary health care services lag behind other countries. Home care services do not adequately meet seniors' needs. Prescription drug costs remain beyond the means of many Canadians, leading to one in ten unfilled prescriptions and to skipped doses. Canadians' slight increase in life expectancy has been overpowered by a wave of conditions like diabetes, and the number of Canadians with two or more chronic conditions rose to 31 per cent by 2010. Understanding Canada's current position enables the Health Council to present a way forward, based on an approach

called the "Triple Aim," that was first introduced by the US-based Institute for Healthcare Improvement. The Health Council outlines an approach for setting

balanced goals and actively supporting key enablers to achieve them, something the 2003 and 2004 health accords did H not do. ■

Medical students recommend tweak to loan forgiveness program The president of the Canadian Federation of Medical Students says federal student loan forgiveness for family doctors and nurses willing to work in rural and remote communities is a step in the right direction. Jesse Kancir made the comment after Candice Bergen, minister of state for social development, announced in Winnipeg that close to 1150 family doctors and nurses have received Canada Student Loan forgiveness. Kancir said it is not surprising there is significant uptake for the program given the debt load many medical students carry. However, the Canadian Student Loan Program (CSLP) still requires medical residents to make payments on both the principal of the undergraduate

loan and interest accrued during postgraduate residency training, he said. Many residents consolidate their Canadian and provincial-territorial student loans into a private bank line of credit with a lower interest rate, or they take part in a provincial-territorial loan relief program during residency. ''These physicians would be ineligible for the new CSLP relief program,'' Kancir said. ''Consequently, the incentive to practice in a rural or remote community is diminished.'' Five provinces – British Columbia, Alberta, Manitoba, Ontario and Prince Edward Island – offer medical residents loan and interest relief on the provincial portion of the Canada student loan durH ing residency training. ■

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falling short

For Canada’s health care system it was a year of transformation – something that seems to be the norm nowadays. And that’s a good thing. With changing demographics within our population, an abundance of new technology, and access to more information than ever before, transformation is a sign that we are moving forward. I often find myself drawn to conversations about healthcare. Over the last seven years I have noticed there is only one thing Canadians like to talk about as much as the weather and that’s their most recent experience in our health system. What I find particularly interesting is the transformation I have noticed in these conversations. As recently as three years ago most conversations I overheard or took part in, inevitably turned into a rant about how terrible our system is. A friend who couldn’t find a family doctor, a neighbour who had to wait 10 months for a hip replacement. Very rarely did anyone have anything good to say, other than, “At least it’s free.” Which was always met with: “You get what you pay for.” What I have noticed is that the negative conversations about our health system are more often interspersed with stories


Theo Expe retical rie Prac ntial tical

Buddhist Psychology Retreat Finding Peace within the Storm For all Health and Helping Professionals January 9-11, 2014 The Ecology Retreat Centre, Hockley Rd. (East of Orangeville)


How do we live with our hearts open to the suffering of the world and ourselves and not be drowned by it? In the face of overwhelm, our protective instincts, can take us away from the present and even see only terror and suffering in the present. But where else can healing happen? Learn to make that journey to be more present and effective.

Don Ferren Ph.d, C Psych., Buddhist 705.749.6145

of good experiences – a neighbour whose mother received outstanding end-of-life care, an acquaintance whose young daughter was diagnosed with cancer and received chemotherapy the next day. This is encouraging. This month Hospital News highlights many successes of our hospitals over the last year: The first Canadian single site gallbladder removal surgery (pg. 14), shortening the hospital stay for prostate cancer surgery patients (pg.18), a new tumour bank that will bring breast cancer discoveries to the bedside more quickly (pg.23), and the list goes on. Our system is transforming. In some areas, efficiencies are increasing as we adopt new technology and streamline care. Transparency is increasing and patients can now see how their local hospital is doing on a number of performance indicators (cover story). Measurements are being implemented to find areas where efficiencies can be further improved. Huge strides are being made. But it’s not enough. Numerous associations, health quality councils and health leaders have sounded the alarm. Change needs to happen at a much faster pace, and on a much larger scale. A recent Health Council of Canada report ‘Better health, better care, better value for all’ indicates that with some exceptions, changes to healthcare have not kept pace with the evolving needs of Canadians. In fact, our health care system is not as good as we think it is. The reality is troubling. In spite of being one of the top spenders on healthcare (internationally), when compared to other OECD countries, we aren’t doing all that great of a job. According to the report, Canada ranks near the bottom in areas like wait times for elective surgeries, being able to get a timely appointment with your family doctor and electronic health records (EHR). Ten years ago the health accords were developed to improve healthcare – and timely access to it across the country. Here

Kristie Jones, Editor

...come and sit together

ADVISORY BOARD Jonathan E. Prousky,

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

Cindy Woods,

Barb Mildon,

RN, PHD, CHE , CCHN(C) VP Professional Practice & Research & CNE, Ontario Shores Centre for Mental Health Sciences Whitby, ON

Senior Communications Officer The Scarborough Hospital, Scarborough, ON

Helen Reilly,

610 Applewood Crescent, Suite 401 Vaughan Ontario L4K 0E3 TEL. 905.532.2600|FAX 1.888.546.6189










Publicist Health-Care Communications Toronto, ON



we are 10 years later and 25 per cent of Canadians still report waiting over four months for elective surgery (compared to 33 per cent in 2005). Canada ranked last of 11 countries – Germany ranked best at zero per cent. Most Canadians who are sick can’t get an appointment with their family doctor that day or the next day. At 47 per cent, Canada ranks last out of 10 countries in primary care doctors providing same-day or next-day appointments – France ranked best at 95 per cent. What’s more disturbing is that in 2004 14 per cent of Canadians reported not having a family doctor – in 2010 that number had risen to 15 per cent. It’s mind-boggling that every Canadian doesn’t have an EHR. In Ontario, a special agency was created to do this in 2008! After a huge scandal and an auditor’s report revealed $1billion dollars in taxpayer’s money was wasted - here we are nearly six years later and only two in three Ontarians have an EHR and only 57 per cent of Canadians. Long wait times cost the system more in extra care while patients are in cue, not having access to a physician in a timely manner usually results in an expensive visit to the emergency department, a complete misuse of resources. If every Canadian had an EHR - it would further streamline care and prevent unnecessary and duplicate diagnostic tests, saving money in the long run. The changes in care Canadians received over the last decade have fallen short. While many of us are having improved experiences in the health care system, the reality is that we don’t know any better. We know that compared to 10 years ago in many areas, we wait less and receive more efficient care. But we aren’t getting our money’s worth. As long as we are willing to accept the status quo, we won’t see the transformation required to ensure our system is sustainable and there when we H need it. ■

Jane Adams,

President Brainstorm Communications & Creations Toronto, ON

Bobbi Greenberg,

Manager, Media and Public Relations. Mississauga Halton Community Care Access Centre

Dr. Cory Ross,

B.A., MS.C., DC, CSM (OXON), MBA, CHE Dean, Health Sciences and Community Services, George Brown College, Toronto, ON

Akilah Dressekie,

Senior Communications Specialist Rouge Valley Health System

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Royal Victoria Regional Health Centre’s (RVH) Dr. Renee Hanrahan (right), is trained as both a cancer surgeon and a plastic surgeon, and able to perform cancer surgeries and reconstruction during the same operation. She catches up with her patient, Marie Plummer, who also works at RVH as a lab assistant in microbiology.

Innovative breast cancer surgery one of the keys for survivorship By Donna Danyluk or Marie Plummer the words cancer and death were synonymous. She’d already lost her sister to the disease and so when she found a lump in her own breast she was terrified. “I thought, ‘It’s cancer – I’m dead’,” says Plummer. The following week was a blur as Plummer underwent a series of tests each leading her closer to a diagnosis she feared would be the worst. When Plummer’s physician met her in his office the tears in his eyes confirmed her suspicion – it was cancer.


“That’s when I finally allowed myself to have a breakdown and immediately I wanted both my breasts off,” says Plummer. However, the lump, a 2.4 cm aggressive stage-two cancer, would first be treated with chemotherapy – a treatment which is available at Barrie’s Royal Victoria Regional Health Centre (RVH) where she works as a lab assistant in microbiology. “When I found out I could have my treatment here at RVH, I felt like I had won the lottery – isn’t that crazy?” says Plummer. “I went through it fairly well. I lost my hair and forty pounds and I was always exhausted – it’s no picnic. I had

pretty good spirits, but there were a few pity party days for sure.” Yet, there was more bad news to come – chemotherapy was not enough. The next step would be radiation. Plummer opted out and went back to her first thought – double mastectomy. “A double mastectomy gave me peace of mind so that I could calm down about getting breast cancer a second time. I am a huge worry wart and still to this day I stress about cancer rearing its ugly head somewhere else in my body,” says Plummer. That decision led Plummer to RVH surgeon Dr. Renee Hanrahan, where she got the first piece of good news in a long time. Dr. Hanrahan can perform both cancer and reconstructive surgery during the same procedure. RVH has made it a priority to drive clinical excellence and offering this service to the women of Simcoe Muskoka is one way to take advantage of RVH’s expertise and technology to provide the best care close to home It meant Dr. Hanrahan could perform Plummer’s double mastectomy and then


CONTACT STEVE BABOR Telephone # 905-737-6222 Email:

immediately reconstruct her breasts, a procedure that requires the expertise of a cancer surgeon and then a plastic surgeon. Dr. Hanrahan is trained in both disciplines. In fact, it was a friend’s illness that gave her the motivation to pursue this unique specialty. “Watching my best friend go through her cancer journey taught me more than any text book. I love what I do and I’m fully supported by RVH,” says Dr. Hanrahan. “My training allows me to remove tumors, perform lumpectomies and mastectomies and reconstruct the breasts, all while following strict cancer standards.” And if Dr. Hanrahan does need the help of a plastic surgeon for reconstruction that requires the use of tissue from the woman’s back or stomach, she calls on the expertise of Dr. Agnes Hassa, RVH plastic surgeon. “Eighty-seven per cent of women will survive this disease but they don’t need to be reminded of it every time they look in the mirror,” says Dr. Hanrahan. “This surgery is one of the keys for survivorship. It gives women immediate reconstruction and gets them past that phase where they are waiting for it to be done.” Dr. Hanrahan says most women are eligible for some form of reconstructive surgery, however in some cases it is not suitable or safe. “To have this procedure available here at RVH is phenomenal,” says Plummer. “Not only does having the double mastectomy and reconstruction at the same time cut down on subsequent surgeries, but it also allows women the opportunity to have their bodies repaired – to be as normal as they can be – after fighting breast cancer. It is not only the physical, but the mental aspect as well. Having the two procedures done at the same time is very critical to a H woman’s recovery and well being.” ■ Donna Danyluk is with Royal Victoria Regional Health Centre’s Corporate Communications department.





A year of rebuilding at ORNGE By Dr. Andrew McCallum ith a helmet on and securely strapped into my seat in the back of an air ambulance, we lifted off from the London airport one morning on an early spring day. It had been years – decades, even – since I treated a patient in the back of a helicopter, but on this occasion, I was along as an observer. Our crew consisted of two highly-qualified flight paramedics and two experienced helicopter pilots, each of whom have devoted their careers to helping some of the most critically ill and injured patients in Ontario. En route to a call for an on-scene response, we soon encountered some unforeseen bad weather. Our pilots made a responsible decision: conditions were unsafe for flying. We would have to turn back, with the land EMS crew responsible for completing the transport.


Much of the past year has been devoted to developing a renewed vision for the organization and mapping out plans for a sustainable, high-quality air ambulance system. Back at the base, we soon received another call for service, this time to transport a critically ill patient from a small Southwestern Ontario hospital to a larger facility in London capable of providing the specialized care required. While the poor weather did not allow for a flight, we departed with an Ornge critical care land ambulance instead. From the moment our paramedics arrived at the patient’s bedside to the receiving bed at London Health Sciences Centre, they provided exemplary care and ensured the patient reached her destination safely. Their actions that day made me proud to call them colleagues. My “rideout� at the London base sums up many of the issues I’ve encountered in my first year as President and CEO of Ornge: The logistical and technical challenges of delivering our service; the pride and professionalism demonstrated by our staff; the collaboration among multiple partners throughout the transport process; and finally, the promise of a highly functioning air ambulance system for the people of Ontario. As I reflect back on the year that was, I believe we have made progress but we have some way to go. Sadly, 2013 will also be remembered

for the tragic events of May 31, when an Ornge air ambulance helicopter crashed in Moosonee, claiming the lives of Captain Don Filliter, First Officer Jacques Dupuy, and Flight Paramedics Chris Snowball and Dustin Dagenais. With the help of the EMS community and other partners, we were able to honour their memory in a dignified and solemn ceremony. The accident touched each member of the Ornge team in a profound way, and we continue to hold the memory of these men in our hearts. This year was about breaking with the past. To that end, we came a long way in dealing with a variety of issues inherited from previous leadership. We began by completing and installing an interim solution to concerns over the configuration of our AW139 helicopter medical interiors, with considerable progress made toward a permanent solution. We completed the sale of assets that no longer fit into the organization’s plans, including two surplus AW139 helicopters that had been in storage and were not being used for patient care. In dealing with these legacy issues, we are committed to using taxpayer dollars wisely and providing value for money. Some important operational improvements are off the ground. To enhance the safety of patients and crews, we are installing solar lighting at 91 unlit helipads across Ontario, with further ongoing study on additional technologies that will further augment the safety of our aircraft. The implementation of a new computer-aided dispatch (or CAD) system is also underway, which will help us more efficiently dispatch our crews and improve our ability to gather data and information with the added plus of giving updates to hospitals. Beyond our day-to-day improvements, we are looking to the future. I firmly believe if you don’t know where you are going, you are unlikely to get there. As a result, much of the past year has been devoted to developing a renewed vision for the organization and mapping out plans for a sustainable, high-quality air ambulance system. We began the process by defining our core mission – providing care for our patients while transporting them safely to the healthcare they need – and updating the organization’s values: Safety, Excellence, Integrity, Preparedness, and Compassion. All of this took place with the input of our staff. I see three broadly-defined areas worthy of specific concentration. First, we need to increase transports that improve patient outcomes. This means ensuring we respond to the right calls with the right vehi-

cles, freeing-up resources for patients who need our helicopters, airplanes and land ambulances the most. Second, it is essential to improve the integration of the patient transport process. In practical terms, this means simplifying and streamlining the process, and opening up new avenues for sharing information among partners so hospitals and other stakeholders have fewer steps in arranging a transport. And finally, we need to devise a financial plan to ensure the long-term viability of the air ambulance system. Naturally, these are issues worthy of considerable debate and discussion. To encourage an open dialogue on these and other topics, Ornge hosted a two-day strategic planning session in September. We in-

vited a number of stakeholder representatives – including unions, hospitals, LHINS, and the Ministry of Health and Long-Term Care – to offer their perspectives and input to help us formulate a roadmap going forward. The result will be a three year plan for the organization which will be implemented beginning next year. It is time for the next chapter in the Ornge story to be written. We still have much work to do in making that happen. Change takes time, but with a revitalized and reenergized organization, we can fulfill our commitment to our patients and to all H Ontarians ■Dr. Andrew McCallum is President and CEO of Ornge.

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Movember helping break the silence in men’s mental health ovember, the global charity that raises funds and awareness for men’s health, has been changing the face of men’s health through the power of the moustache in Canada since 2007. Last year 247,441 Mo Bros and Mo Sistas raised over $42.6 M and started 2.72 billion conversations globally about men’s health. Movember has been supporting men’s mental health since 2003 and in Canada since 2012. In Canada, one in five men will experience a mental illness this year. When you compare the life expectancy of men and women, there is a four-year mortality gap and mental health is a critical issue contributing to this. By addressing men’s mental health Movember aims to help close that gap. Thanks to the success of the 2012 campaign, Movember announced $13 M in funding for men’s mental health initiatives this past year. In 2012 the Movember Foundation established the Canadian Men’s Health Network (CMHN) as a strategy to address the challenges in men’s health in Canada. The CMHN brings together some of the top scientific and medical professionals from across the country to collaborate on identifying and addressing men's health issues, and men’s mental health was the first priority issue addressed by the Network. Collaboration and knowledge sharing across medical professionals is likely to make a


more significant impact on men’s health than through groups and individuals working in isolation. “Thanks to the power of moustaches we are helping Canadians become more aware and proactive about not only their physical health but mental health and the challenges faced by those men living with and beyond mental health issues� says Pete Bombaci, Country Director, Movember Canada. “At Movember we are about creating conversations to help change the face of men’s health, and our first men’s mental health funding is undoubtedly a great step forward to bringing attention to an area that deserves great attention.� The Canadian Men’s Health Network (CMHN) convened for the first time in 2012 and announced two Request for Applications (RFA), both aimed to improve the lives of those men living with and beyond mental illness. Recipients of the first RFA were awarded in October 2013,

representing Movember’s first announcement of funding for men’s mental health and one of the largest non-governmental investments in the field to date. A total of seven projects throughout Canada have been awarded. These collaborative, inter-organizational and pan-Canadian programs will work to achieve significant results in the priority areas of destigmatization, prevention, and awareness across a full spectrum of demographics of Canadian men and the diverse mental health challenges they face. By investing in the most promising programs regardless of organizational boundaries, the CMHN and Movember lend support to new fathers, teenage boys, First Nation boys and men, Asian communities, older men facing retirement, and young men in the university setting. Each program aims at improving the state of men’s mental health. The seven funded programs include: •McGill University – Development and

Pilot Evaluation of a Multimodal E-Health Intervention to Promote the Mental Health of Men at Risk for Depression •Ryerson University – Reducing stigma of mental illness among boys and men in Asian communities in Canada: An innovative intervention study •Kids Help Phone – mTalk: a Male Mental Health Counseling and Information Program for Teens •Centre for Addiction and Mental Health – Acting locally to have a national impact: A participatory action approach to addressing First Nation boys’ and men’s mental health •Lawson Health Research Institute and Western University – Enhancing Psychological Resiliency in Older Men Facing Retirement: Testing a Meaning-Centered Group Intervention •Queen’s University – The Caring Campus: An Intervention Project •University of British Columbia – Masculinities and men's depression and suicide Network To learn more about Movember, to get involved or to donate visit www.movemH ■Movember is a global charity that raises funds and awareness for men’s health through the power of the moustache. Movember Canada is based in Toronto, Ontario.






Healing retreats for young women with burn and trauma injuries By Lesia Cartelli ichelle, an Ontario native was travelling in the US with her family when they were involved in a tragic accident. The accident left Michelle with third degree burns covering 74 per cent of her body and a very long road to recovery. With our hospitals’ dedication, commitment, and medical advances in treating burns and trauma, patients who survive an 80 per cent plus burn injury are common. Just twenty years ago their survival rate was dismal. Today’s problem lies in the aftercare of that burn patient once they are discharged. Their lives are saved, but their tomorrows are a nightmare of stares, unwanted questions and worse – gawks from children. Hating to leave home, they suffer a “social death,” and have no tools for handling their very different appearance. Particularly affected are girls and young women, for whom appearances are seemingly everything. Enter Angel Faces.


Angel Faces is a nonprofit organization that provides healing retreats and ongoing support for adolescent girls and young women with burn/ trauma injuries. Angel Faces is a nonprofit organization that provides healing retreats and ongoing support for adolescent girls and young women with burn/trauma injuries. It provides tools to help them achieve their optimum potential and develop meaningful relationships for themselves, their families, and their communities. Adolescent girls like Michelle, flock to the retreats from all over the world, including Canada. They arrive hungry to overcome their fear of being accepted despite the way they look – catastrophic scars crawling across their once beautiful faces and bodies. They arrive yearning to embrace who they are, but filled with fears of never being loved and questions like “why me?” I created and launched Angel Faces from my own pain as a young girl, so my answer, “Why not you?” is a response from the heart and from experience. I was severely burned over 50 per cent of my face and body in a natural gas explosion at the age of nine. My grandparents’ home was destroyed. I tossed and turned on my journey with severe scars – I knew pain both inside and out. Having continuously done everything I could to heal and live fully, I

learned that the accident brought its blessings. As an adult woman, I knew I could help those who had been burned, who were fumbling. Each retreat the girls arrive with scars of various shape and depth over what once was fresh skin. The depth of their scars is not even close to the depth of the inner pain that came with those scars. Some have lost a family member in the tragic accident; most have lost their childhood. Their suitcases are full of clothes and toiletries but the heavier burden is the invisible suitcase of pain and rejection they carry with them everywhere. From the cozy living room to the pool, to the yoga field and dining room, they drag their invisible suitcase behind. Angel Faces’ retreats are run by a team of devoted volunteers that includes a licensed psychologist, an art therapist, nurses and fire captains. Best-of-the-best women who are willing to leave their own pain, struggles and challenges at home, they bring their love, life lessons, compassion, expertise, time, strength, courage and spiritual wisdom to girls they have never met. We have a powerful force of commitment and duty to pull the girls up from pain and direct them onto a goal setting future. As a non-profit, Angel Faces relies on its donors and supporters. Our program touches lives. As evidence, we have hundreds of communiqués from the parents, “Thank you for giving my daughter back,” our award-winning published research at the American Burn Conference, and the continuing progress of the girls themselves. “When I flew out here to Angel Faces, I sat on the plane with my head down – so scared the person next to me would look at me or talk to me,” says Angela, a first time Angel Faces participant. “When I flew home, I introduced myself to my seatmate and said hello – I have a whole new life waiting for me.” Angela doesn’t need to pay a baggage fee for her invisible luggage filled with pain anymore. It no longer exists. Angel Faces works. Michelle first flew out to the California retreat in 2010 after applying online and receiving a scholarship to cover the cost. “I have attended the retreat first as a girl then I attend the mentorship/leadership retreat as a young woman. For girls with any type of facial disfigurement, at any stage in their life I highly recommend the retreat. It’s amazing. I came back having received so much love and made great relationships. If you attend you will leave with so much more than you went with,” Michelle says. Girls are often referred from burn/ trauma centers or they can apply online

Participants at an Angel Faces retreat in California. The program is open to Canadians and applications can be sent online at at for the retreats that target their age group. The fee to attend varies the ranging from $1,500 – $3,500 per participant. Most girls and young women who have suffered a trauma/burn cannot pay – Angel Faces raises

money and is able to offer scholarships and H sponsorships. ■ Lesia Cartelli is the Founder/CEO of Angel Faces and can be reached at



10 Focus

Breast cancer surveillance program ensures comprehensive care for patients post-treatment By Andrea Griepsma eceiving a breast cancer diagnosis can be a life-altering blow for many women. Following the often-unexpected diagnosis, these women face a marathon of tests and treatments, which can be both mentally and physically exhausting. For the many women who go on to beat the disease, they now face a new journey â&#x20AC;&#x201C; rebuilding their lives following cancer. Every year, more than 23,000 women are diagnosed with breast cancer in Canada. Newmarketâ&#x20AC;&#x2122;s Stronach Regional Cancer Centre at Southlake treats almost 500 of these patients, and medical oncologist Dr. Farrah Kassam and nurse practitioner Brenda Wilks witness first-hand how challenging cancer treatment can be. Yet, for every struggle, they also see incredible feats of strength and empowerment; strong women who bravely commit to overcoming this disease and to getting their lives back post-treatment. â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;d often have patients coming back to my office after their treatment asking â&#x20AC;&#x2DC;What now?â&#x20AC;&#x2122;, unsure of how to pick up the pieces and move on,â&#x20AC;? Dr. Kassam says. â&#x20AC;&#x153;Our relationship with patients shouldnâ&#x20AC;&#x2122;t end the day they walk out the door after their final treatment. We have a responsibility to ensure these patients understand their role in the path to survivorship and to provide them with the tools and support they need along the way.â&#x20AC;? According to the National Cancer Institute, the term â&#x20AC;&#x153;survivorshipâ&#x20AC;? applies to an individual from the time of diagnosis, through the balance of his or her life. The patientâ&#x20AC;&#x2122;s family members, friends and caregivers are also included in this definition, as they too are impacted by the survivorship experience. In 2011, Dr. Kassam and Ms Wilks introduced the Cancer Transitions program, a six-week educational program developed by the Livestrong Foundation and the Cancer Support Community designed to help cancer survivors make the transition from active treatment back to their regular lives. The program offers educational sessions on nutrition, spiritual well-being, exercise and life beyond cancer. â&#x20AC;&#x153;Patients have told us the Cancer Transitions program helped them build back the dismantled pieces of their lives,â&#x20AC;? Ms


Medical oncologist Dr. Farrah Kassam (second left) and nurse practitioner Brenda Wilks meet with breast cancer survivors, Patricia Pernokis and Margaret Holdsworth, who are participating in Southlake's Breast Cancer Surveillance Program. Photo credit: Jim Craigmyle Wilks says. â&#x20AC;&#x153;It empowered them to take control and gave them the tools and support they needed to successfully rebuild their lives. The success of that program showed us that the more support we could offer patients, the better.â&#x20AC;? Dr. Kassam says significant advances in breast cancer diagnosis and treatment means the population of breast cancer survivors is growing. â&#x20AC;&#x153;These patients deserve high quality follow-up to detect recurrences (i.e. surveillance) and to manage survivorship issues,â&#x20AC;? she says. With this in mind and following the resounding success of the survivorship program, Dr. Kassam and Ms Wilks, in collaboration with Cancer Care Ontario, set out to create a formal Breast Cancer Surveillance Program. Launched at the Stronach Regional Cancer Centre in July 2013, the program is for patients who have completed active treatment, such as surgery, radiation and/ or chemotherapy. The patientâ&#x20AC;&#x2122;s follow-up care is shared and coordinated between their primary care physician, medical oncologist and surgeon. The program en-

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courages early involvement of a patientâ&#x20AC;&#x2122;s primary care physician and works by providing patients and their primary care physicians with the tools and support they need to actively participate in breast cancer surveillance and survivorship.

According to the National Cancer Institute, the term â&#x20AC;&#x153;survivorshipâ&#x20AC;? applies to an individual from the time of diagnosis, through the balance of his or her life. Designed to follow the patient throughout their survivorship journey, the program relies on the use of a paper â&#x20AC;&#x153;passportâ&#x20AC;?, which includes the patientâ&#x20AC;&#x2122;s diagnosis details, treatment summary and a detailed schedule of follow-up appointments and tests relevant to their care. The patient carries this passport with them to all appointments, ensuring they have a single point of reference to track and schedule appointments and relay information to other members of the health care team. Prior to the introduction of this program, patients left active treatment with multiple follow-up dates, times and locations with different doctors. With no formal way of tracking and coordinating which doctor they were supposed to see and when, patients often had duplication of follow-up visits and family doctors were typically left out of early follow-up care. â&#x20AC;&#x153;I believe patients do better in a controlled environment; they are better able to cope when they know whatâ&#x20AC;&#x2122;s coming and what is expected of them, and the passport offers this,â&#x20AC;? Dr. Kassam says. â&#x20AC;&#x153;The passport and surveillance program allow us to empower patients with the knowledge and understanding about their care, while

at the same time providing primary care physicians with the tools and information they need to be contributing players in their follow-up care plan.â&#x20AC;? In addition to the paper passport, Dr. Kassam and Ms Wilks have created a â&#x20AC;&#x153;breast cancer survivorshipâ&#x20AC;? link on the hospitalâ&#x20AC;&#x2122;s website to allow patients and other health care professionals to easily access information and tools that may be beneficial to their recovery. A mobile application of the passport, set to be introduced soon, will provide patients with greater flexibility in terms of scheduling and recording their appointments and offer an automated reminder system for upcoming appointments. Dr. Kassam and Ms Wilks profiled the Breast Cancer Surveillance Program to primary care physicians in early fall. They also hope to be able to expand the program to include other hospitals in the region and colorectal cancer patients. So, what began as a survivorship course at the Stronach Regional Cancer Centre two years ago has now flourished into a comprehensive patient-centred approach to â&#x20AC;&#x153;survivorshipâ&#x20AC;? care, designed to ensure patients have the medical, spiritual and emotional support they need to live healthier lives following cancer treatment. â&#x20AC;&#x153;We believe weâ&#x20AC;&#x2122;re onto something powerful here,â&#x20AC;? Dr. Kassam says. â&#x20AC;&#x153;We think this has the potential to positively change the delivery of follow-up care for all cancer patients.â&#x20AC;? Additional information regarding the Breast Cancer Surveillance Program can be found on the hospitalâ&#x20AC;&#x2122;s website at or by calling 905-895-4521, ext. 6627. For general information about breast cancer, visit the Canadian Breast Cancer Foundationâ&#x20AC;&#x2122;s H Ontario chapter website at â&#x2013; Andrea Griepsma is a Corporate Communications Specialist at Southlake Regional Health Centre.


Community hospital

“Living Labs” key to our future By Donna McRitchie ecently, a young woman in her mid-30s was referred to me by her family physician. She is a mother of two children under the age of seven who had discovered a lump in her breast. Our team at North York General Hospital (NYGH) ensured that she had a timely ultrasound and mammogram, which provided enough information for a decision to biopsy the lump. The biopsy confirmed a diagnosis of breast cancer. This process took place over the course of a few days and surgery was scheduled for a date within two weeks. This case is not exceptional; almost 23,000 women in Canada will receive a similar diagnosis this year alone, and I see several new breast cancer patients each week. Providing the best possible care to each of these patients is the ultimate goal. Researchers in Canada and around the world have made very good progress in understanding the biology of cancer and in discovering and developing new therapies to improve long-term survival rates. That work is truly amazing. Advances in health systems, including our ability to provide patients with the care they need in a timely, safe, and efficient way can be equally effective in improving patient outcomes. This is an increasingly important area of focus, as these advances are essential to the longterm sustainability of our entire health care system. In Ontario, some measures estimate that 80 per cent of hospital care takes place in community hospitals like NYGH. Although most of the ‘discovery’ research in Canada occurs in academic health science centres, leading community hospitals have the opportunity to evolve more into “living labs,” where researchers can study and improve the processes by which care is delivered. A critical lens and an innovative spirit should be applied where the bulk of care is delivered, with the goal of improving our systems each day. Key to our success moving forward involves a relentless dedication to systems improvements. At NYGH, for example, we were one of only three large hospitals in Canada to achieve Stage 6 of the Healthcare Information and Management Systems Society, which measures progress in electronic health records implementation. These records help us move patients through the system, to the care they need in an efficiently and safe manner. We enjoy a seamless collaboration with a large, interdisciplinary communitybased family health team, ensuring that patients can transition through the system and receive the care they need in the most appropriate setting. We also employ a cadre of quality-improvement specialists, who monitor patient flow and outcomes, proving that a moderate up-front investment can yield significant long-term results.


Focus 11

Low compression alternative for breast cancer screening By Shalyn Littlefield etting a mammogram every two years for breast screening helps make sure any problems are caught at an early stage. The earlier you find it, the better. Early detection when the cancer is small leads to an increased chance of successful treatment and a less likely chance of the cancer spreading. Most women over the age of 50 should be familiar with the mammography screening procedures. A plate is pressed down to slowly flatten the breast while an X-ray image is taken. While this may not be the most comfortable procedure for anyone, compression of the breast can be particularly painful in younger women, who tend to have denser breast tissue. More importantly, the dense tissue in young women also leads to a lower chance of mammography being effective because the tumour is harder to detect using this test. There is a clear need to find a way to effectively detect tumours in these young women who are at a high risk of developing breast cancer, in order to identify the cancer in its early stages. Dr. Alla Reznik, of the Thunder Bay Regional Research Institute and Lakehead University, is venturing to do this, with the development of her Portable Positron Emission Mammography (PEM) device. Dr. Reznik stresses that the importance and significance of the mammography test should not be underestimated. “Mammography remains a primary tool which


significantly reduces mortality from breast cancer and is still the most efficient way of detecting breast cancer in women over 50 years of age. However, there is always room for improvement, especially in cases of women who have to be tested very often at early ages.” She is referring to women who have a family history of breast cancer, who are therefore at an increased risk of development. Breast cancer in high-risk women is known to have early onset, and women have to be screened yearly at a substantially younger age than women at an average risk.

As an alternative to mammography, patients who are at high risk for breast cancer may one day benefit from a new imaging technique currently being developed So how does the PEM technique work differently than mammography? Mammography uses low dose X-rays to image the breast, showing the dense mass of a tumour in contrast to the breast tissue. But in dense breasts, this can make the image more difficult to interpret. PEM, on the other hand, is a molecular breast imaging

modality, which distinguishes biological processes and functional properties of the cancerous cells compared to the normal cells, using a radiotracer to highlight areas of abnormality. This allows for detection of small masses, regardless of their density. Dr. Reznik’s first goal is to build a prototype model of this device, with the help of her research team at the Thunder Bay Regional Research Institute and graduate students of Lakehead University. Once the technical innovation is complete, she is excited to embark on clinical trials using her technology to prove it is a suitable screening technique, with patients at the Thunder Bay Regional Health Sciences Centre. She also has high hopes to one day introduce this portable device into Thunder Bay’s surrounding regions and communities to increase remote access to screening. Dr. Reznik greatly anticipates the day that the women of Thunder Bay who are at high-risk for breast cancer can benefit from the use of the PEM screening device. “I am thrilled to be a part of the Thunder Bay Regional Research Institute with its commitment to translational research, providing a well-defined pathway to clinics particularly through its partnership with the Thunder Bay Regional Health SciH ences Centre.” ■ Shalyn Littlefield is the Research Protocol Development Specialist at the Thunder Bay Regional Research Institute.


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Continued on page 13



12 Focus

Top Causes of death in Canadian Hospitals

Every year more than


Chronic obstructive pulmonary disease

Canadians die in hospital


This is about 65% of all deaths in Canada


(Source: Statistics Canada)

Heart Failure

Blood stream infection


Lung Cancer

How healthy is our health care system? Continued from cover Is there somewhere that people can go, for example, to find out how their health system is doing at the local level? Is it possible to learn how well different parts work together – or not – to meet the needs of patients? Can we compare how Canada’s health system stacks up to other countries? Could all this information be available in one place? The answer is “Yes. We can now get a more comprehensive picture of how we are doing at” Launched in November, this new website was developed with the public in mind by the Canadian Institute for Health Information (CIHI). It uses clear language and appealing infographics to guide visitors through a virtual cross-country journey of the health system, comparing performance across Canada at various levels – by province, by region and, in some cases, even by hospital. Patients and health care professionals alike have already found it valuable. The media responded positively as well, with one daily newspaper referring to the site as “a treasure trove of information.”

For the people, by the people

As users and funders of the health system, Canadians want and deserve to know how well it’s performing. So CIHI set out to build a website that would focus on the areas of the health system that the public said was of greatest interest. How? We started the project with a robust public consultation process, engaging more than 3,000 people from across the country through a combination of online


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randomized sampling and in-person smallgroup dialogues. This eventually led to the engaging and user-friendly site reflecting five health care themes, those identified as top-of-mind for Canadians. Interwoven with these themes is the underlying but equally important issue of equity: Canadians receiving care based on clinical need, regardless of disparities in age, sex or socio-economic status. Within the five identified themes, the site shows that there are mixed results in terms of Canada’s health system performance: it’s doing well in some areas, but improvements are still needed in others. Access: Can you get the health services you need, when you need them? 1 in 6 Canadians waits three months or longer to see a specialist – even though the number of specialists has increased since 2003. Quality of Care: How good is the care you are receiving and is it safe? A significant drop in hospital deaths suggests that the quality of hospital care is improving overall in Canada; however, 1 in 12 Canadians is readmitted to hospital within 30 days of discharge and national results are not improving. Spending: How much do the health services you use cost the system? Spending on health care varies greatly across the country, even after taking age differences in the population into account. Health promotion and disease prevention: How well is the system working to help you stay healthy and avoid getting sick? While smoking rates are declining in Canada, obesity rates continue to rise. Obesity rates for children have tripled in the last 30 years. Health outcomes: Are Canadians actually getting healthier? Three out of four Canadian children are developing well before entering Grade 1. Using these themes as a cornerstone, builds on previously released data by combining it with new information. It features 15 comparable indicators – or measures of health system performance – that show performance from the national level down to the local and facility levels. Some examples: •How many patients have repeat hospital stays for mental illness •The number of residents in long-term care facilities who are taking anti-psychotic drugs without a diagnosis of psychosis •The percentage of deaths in Canada that

Heart Attack (Source: CIHI)

See. Know. Share.

How long can Canadians expect to live, on average?

Where we go from here

Consider this:

are from preventable or treatable causes •How long people can expect to live based on their province or territory of residence CIHI’s way of making health indicators more understandable, meaningful and useful is through the use of infographics on the site. Each health care theme is represented with an icon. Clicking on the icon, visitors can browse through sub-categories to explore and compare further. The “Spending” icon, for example, is broken down into “Ageadjusted public spending per person” and “Average Cost of a hospital stay.” To involve visitors further and to encourage the distribution of knowledge, the site also allows visitors to easily share what they’ve learned through social media channels. is just one of several steps in providing the public with more accessible information about its health system. In 2014, CIHI plans to release more performance measures for regions and hospitals in a similar website. This will replace the Canadian Hospital Reporting Project (CHRP) site at cihi. ca, and provide details of particular use to people working in the system. We will also host a national consensus conference to bring together stakeholders for a discussion on future priorities as we plan to undertake even more performance reporting and indicator development. In the meantime, OurHealthSystem. ca is intended to serve as a reference to support better decisions and enhance transparency of the health system overall. And to keep the information timely and relevant, CIHI’s goal is to update the site at least once per year. This will help ensure the new website not only continues to be of interest to the public, but also useful for planners and policy-makers within the health care system. After all, it is especially important for them to understand who is doing well to best position them all for an even more efficient, high-quality system. To learn more about Canada’s health system performance and see all of the reH sults, please visit ■ John is President and CEO. Jeremy is Vice President, Research and Analysis at The Canadian Institute for Health Information.

In 1990, only 2 countries in the world had a longer life expectancy than Canada. Now, 11 countries do.

How well does your hospital provide care overall? Are deaths higher or lower than expected?

Consider this:

Hospital death rates have decreased by 18% in Canada over the past five years.


Focus 13

Nurse Practitioner enhances patient-centred care for seniors By Michelle Tadique new Nurse Practitioner role with a special focus on Geriatrics is helping the most frail and complex patients at St. Joseph's Health Centre return home safely with the supports they need. This new dedicated resource within the Health Centre’s Medicine and Seniors Care Program works closely with the interprofessional frontline teams and physicians to pull together the right internal and external community supports as soon as a senior patient is admitted to one of the medicine beds. Stella Cruz is proud to take on this new role as Nurse Practitioner in an area of medicine she is very passionate about. Cruz will be working to support a collaborative and consultative model of care that starts on “day #1”, providing early assessment and intervention that follows geriatric medicine patients throughout their care journey at St. Joe’s. “I can assess patients admitted to the unit with a focus on geriatric medicine, to try and identify all of the issues that have brought these patients into the hospital,” Cruz explains. Providing health care services to meet the needs of the growing number of seniors is a priority. St. Joe’s serves a catchment area where 34 per cent of the population


Stella Cruz, Nurse Practitioner, Geriatrics, in the Medicine inpatient unit at St. Joe’s. is over the age of 65. In the last two years, 13,700 patients over the age of 70 went to the emergency department (ED) for care, with 4,900 being admitted. On average, patient over 70 stayed more than 7.8 days in hospital, compared to 3.5 days for patients under 70 years of age.

Community hospital Continued from page 11

Health care institutions that have the privilege of treating a high volume of patients have the opportunity – if not the obligation – to study, refine and share their successes. At NYGH, colleagues in Mental Health launched a microfinance program to encourage new approaches to care, and they have managed to reduce the number and length of hospital visits by bringing primary care and mental health physicians together in one location.

Real world research is so vital in community hospitals, where there exists an opportunity to study and refine the care provided to large numbers of ‘typical’ patients in real time. To support further research, we recently launched a hospital-wide “Exploration Fund” to seed opportunities for staff and physicians to develop new approaches to improve patient care. One recipient, a nurse, has begun to study a Montessori Elder Care method to help calm disoriented geriatric patients in the emergency department. Another nurse, together with her orthopaedic colleagues, is studying different approaches to pain management for patients undergoing knee surgery.

Ultimately, the plan is to seed the hospital with research chairs that will act as catalysts, studying policy-relevant practice across the enterprise. Plans are underway for a chair in health care delivery to create and disseminate new knowledge in process improvement, a chair in informatics to delineate the impacts of information system innovations on patient outcomes, and a chair in the delivery of care to diverse populations to advance understanding of how different cultures interact with the health care system, among others. That is why real world research is so vital in community hospitals, where there exists an opportunity to study and refine the care provided to large numbers of ‘typical’ patients in real time. This will be vital to health care sustainability. I’m pleased to report that my patient is on her way to recovery and her long-term prognosis is excellent. She has benefitted from a system where family physicians are collaborating with the hospital system, where specialists within the hospital are working as a team, and where technology is effectively functioning to improve safety and efficiency. This system can always be improved, scaled and replicated in other institutions and settings. Each patient deserves this level of care, as does H the entire system. ■ Dr. Donna McRitchie is Vice President of Medical and Academic Affairs at North York General Hospital

For the last several years, St. Joe’s has been working to enhance a senior-friendly philosophy, notes Catherine Cotton, Administrative Program Director for the Medicine and Seniors Care Program. “We have been implementing several strategies in our program and in partnership with other areas in the hospital that enable our senior patients to maintain optimal health and function while in our care so that they can successfully and safely transition home to their families and their lives,” Cotton explains. "We are very pleased to welcome Stella to this role in our program.” Adding a dedicated Nurse Practitioner in the Medicine and Seniors Care Program builds on the success of a project that was started in the ED last year called the First Three Days. The project’s aim was to prevent seniors from experiencing further decline in their function (making sure that patients don’t lose their mobility and can still do normal, every day activities on their own such as eating and getting dressed) while being treated in the hospital, with the goal of sending them home with as much of their independence intact as possible. “This project was very successful and showed that very early assessment, intervention and follow through for geriatric patients helped decrease their length of stay, increase patient satisfaction and identify those patients who may lack much needed support at home – so by having a Nurse

Practitioner in the Medicine Program, it will help us carry this approach through to patients right on the unit,” says Cruz. Elderly patients tend to have multiple, complex medical issues, on top of other financial, social and environmental issues that impact their overall health and wellbeing. “All of these complex pieces have to be taken into consideration before our patients can go home,” says Cruz. “There are several staff and clinicians involved in caring for seniors; it’s a very interprofessional and collaborative approach.” Cruz participates in “bullet rounds”, which are daily update meetings that bring the entire team together to discuss every aspect of their patients’ care. This close collaboration allows Cruz and her colleagues (physicians, nurses, physical therapists, occupational therapists, social workers, pharmacists) to work together in developing discharge plans for patients to get them home safely. In her role, Cruz also meets with patients and their families directly every day from the time they are admitted to a hospital bed from the ED. Over the coming months, the Medicine and Seniors Care Program will continue to evaluate the impact this new strategy is having on geriatric patients’ quality of care and H experience of care. ■ Michelle Tadique is a Communications Associate at St. Joseph’s Health Centre.




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14 Focus

Scientists recognized for innovation in

prostate cancer research By Alisa Kim hree Sunnybrook Research Institute (SRI) scientists won Movember Discovery Grants from Prostate Cancer Canada. The awards are worth $200,000 over two years and support promising new directions in prostate cancer research. Prostate Cancer Canada approved 40 of the 154 applications submitted, for a total investment of $7.7 million. Dr. Stanley Liu, a scientist in Biological Sciences at SRI, scored funding for his research, which looks at how microRNAs (short sequences of ribonucleic acid) help prostate cancer cells evade death from radiation, a main treatment for prostate cancer. "Our goal is to try and make radiation work better in patients. One of the ways we're trying to do that is by figuring out how certain prostate cancer cells are able to survive radiation. If we're able to figure out the wiring and the pathways that govern resistance to radiation, we'll be able to target those pathways," says Liu, who is also a radiation oncologist at Sunnybrook's Odette Cancer Centre. Discovered in 1993, scientists now know that microRNAs regulate which genes are expressed and when. They do this by attaching themselves to messenger RNAs and preventing them from being translated into proteins. More than 700 microRNAs have been identified in people, and several hundred more are thought to exist. MicroRNAs govern the expression of about 60 per cent of all human genes and can suppress hundreds of targets each. "They put the brakes on protein expression," says Liu, who is also an assistant professor at the University of Toronto. "If you put the brakes on a tumour suppressor, then that microRNA can be oncogenic and make a cancer cell more aggressive. On the other hand, if a microRNA targets


Dr. Stanley Liu’s lab is investigating how small fragments of genetic material or micro RNA can make cancer cells resistant to radiation therapy. (These micro RNA may serve as personalized biomarkers to predict which patients have cancers more likely to resist radiation therapy.) Photo Credit: Doug Nicholson, MediaSource components involved in repairing DNA, then those cancer cells might be more sensitive to treatment – if the cells can't repair their DNA as well." Growth in the field of microRNA research has been "exponential," with hundreds of scientific papers published on the topic each month, says Liu. He notes that radiation-induced changes to microRNAs in cancer cells are well documented, but which of the hundreds of microRNAs are the main players in radiation resistance, and the precise mechanisms by which resistance occurs, remains unknown. "If you give radiation to patients, microRNAs change within minutes to hours. We can say things are changing – some [researchers] have reported profiles: 'This is going up, this is going down,' – but no one's said, 'This is one that is actually involved in response to radiation and making cells resistant.' How does that microRNA actually do that? That's a critical area that

hasn't been addressed. That's what we're trying to do," says Liu. In addition to uncovering the biological mechanisms behind treatment resistance,

Liu also hopes to unveil the predictive power of microRNAs, which can be detected in blood, urine and saliva, so that doctors can tailor therapies according to severity of disease. "They're very stable. They can be used as biomarkers, not just in detection of cancer, but also in prognostication – which patients might have an aggressive cancer and might [therefore] need aggressive treatment. It's still in relative infancy, but those are questions we're also interested in." Two other SRI scientists succeeded in their bid for a Movember Discovery Grant. Dr. Charles Cunningham, a senior scientist in Physical Sciences at SRI, gained funding for his research on hyperpolarized carbon-13 imaging of advanced metastatic prostate cancer. Dr. Greg Czarnota, director of the Odette Cancer Research Program at SRI, secured funding for his research on the use of microbubbles to enH hance radiotherapy for prostate cancer. ■ Alisa Kim is a communications officer at Sunnybrook Research Institute, Sunnybrook Health Sciences Centre.

Canadian first:

Robotic single-site gallbladder removal By Marek Kubow da Vinci single-site cholecystectomy, or gallbladder removal, was performed at London Health Sciences Centre (LHSC) for the first time in Canada on September 13 by Dr. Christopher Schlachta, medical director, Canadian Surgical Technologies and Advanced Robotics (CSTAR). “Traditional laparoscopic surgery is performed through four small incisions,” says Dr. Schlachta. “With a single-site robotic surgery, the gallbladder is removed through a single small incision, hidden in the belly button, and patients experience virtually scarless results.” Patient Melanie Sabino, 33, a nurse from St. Mary’s Ontario, says she felt excited to be offered this surgical option. “I was back to normal in just two days. Without a scar my co-workers don’t believe I’ve had surgery.” “This technology represents an exciting


evolution in robotic surgery. In 25 years, we have gone from big incisions, to a series of small incisions for each of the surgeon’s hands, to this development of just one small, hidden incision. This is a whole new world that we plan to apply to even more complex surgeries including colorectal cancer surgery, anti-reflux surgery, kidney surgery, as well as pancreatic and liver surgeries,” says Dr. Schlachta. Dr. Anthony Gonzalez, chief of surgery and minimally invasive and robotic surgery at Baptiste Hospital in South Florida was one of the first surgeons in North America to perform single-site robotic surgery and has since performed 300 single-site gallbladder removals robotically. “Having this surgical option available in Canada is an important first step in offering patients nearly scarless surgery with other more H complex surgeries.” ■ Marek Kubow is a Communications Consultant at London Health Sciences Centre.

From left, Dr. Christopher Schlachta, medical director, Canadian Surgical Technologies and Advanced Robotics (CSTAR), displays the da Vinci single-site technology to Melanie Sabino, the first patient in Canada to receive a single-site cholecystectomy. HOSPITAL NEWS DECEMBER 2013


Focus 15

Working together to expand Ontario’s health care infrastructure

incorporating a new 48,000 square foot facility to improve care and support for those living with HIV/AIDS.

By Jennifer Asals ince its inception in 2005, Infrastructure Ontario has been working with hospitals and other health care partners to renew and expand existing facilities or to build new hospitals. Projects completed to date have delivered substantial benefits to communities across Ontario, helping to bring treatment closer to home for those who need it. Working with our partners across the province, we’ve delivered: •9.7 million square feet of new or renovated hospital space •81 new operating rooms •Nine new emergency rooms •Eight new cancer centres •New cardiac and dialysis treatment facilities. Modernizing Ontario’s hospitals to improve Ontarians’ access to healthcare is an important part of Infrastructure Ontario’s job and 2013 was no exception. All across Ontario, new hospital projects got off the ground or celebrated major accomplishments, such as:


Completed projects

Bridgepoint Hospital (Toronto) In April, Bridgepoint opened its new 10-storey, 680,000 square foot hospital. The new hospital – built to replace the original congested and aging facility – is improving patient care by providing more living space and by doubling the existing therapy space, to include larger, accessible therapy gyms on every patient floor. Markham Stouffville Hospital In March, Markham Stouffville Hospital celebrated the opening of its new wing. The project doubled the size of the hospital with a four-storey addition that added 385,000 square feet to the existing site. With the new tower complete, renovations began on the existing facility. Niagara Health System (St. Catharines) In March, the Niagara Health System opened the doors to its new St. Catharines site. The state-of-the-art facility, with capacity for up to 399 beds, provides the community with enhanced programs and services, replacing the aging St. Catharines General and Ontario Street sites of the Niagara Health System. Eighty per cent of the hospital’s rooms are single patient rooms – the most currently available in a community hospital in Ontario.

Joseph Brant Hospital (Burlington) Infrastructure Ontario worked with Joseph Brant Hospital to issue a request for qualifications in April for a consortium to design, build and finance the construction of its new six-storey patient-care tower and renovations to existing space. When complete, the newly expanded and renovated hospital will provide the growing local community with improved access to a larger, more modern hospital with additional inpatient beds, operating rooms and a range of expanded programs and units.

Oakville Hospital aerial: Once complete, the new Oakville Hospital will be approximately 1.5 million square feet and will provide an increased capacity of up to 457 inpatient beds. Public Health Laboratory (Toronto) In June, construction began on Public Health Ontario’s new Toronto public health laboratory, located at MaRS Centre Phase 2 in downtown Toronto. The new facility will enable Public Health Ontario to remain at the forefront of infectious dis-

Modernizing Ontario’s hospitals to improve Ontarians’ access to the health care is an important part of Infrastructure Ontario’s job and 2013 was no exception.

ease testing, detection and control, while providing essential services and responding to emerging public health issues. St. Joseph’s Healthcare Hamilton, West 5th Campus Soon to be completed and to be opened in 2014, the new 800,000 square foot hospital will provide mental health and addiction care, medical outpatient services, research and academic spaces.

Projects in procurement

Casey House (Toronto) In August, Infrastructure Ontario and Casey House released a request for qualifications to build and finance the Casey House project. The project involves renovating an existing heritage property and

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Peel Memorial Centre for Health and Wellness (Brampton) In June, William Osler Health System and Infrastructure Ontario issued a request for proposals for a new hospital in Brampton. The facility will support Osler’s vision for an integrated health system by providing primary ambulatory and outpatient based care. University of Ottawa Heart Institute In September, Infrastructure Ontario began the competitive bidding process for another hospital project. A request for qualifications was issued to build and finance the University of Ottawa Heart Institute Cardiac Life Support Services Redevelopment project. The project will expand the facility to accommodate the changing needs of the area and will improve access to high quality specialized H cardiac services. ■ Jennifer Asals is a Senior Communications Advisor at Infrastructure Ontario.

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16 Focus


Health care stories that made headlines in 2013 First public cord-blood bank launches in Canada

On September 30th, Canada's first national public blood bank for umbilical cord blood accepted its first donation at the Ottawa Hospital. According to Canadian Blood Services, until then, Canada was the only G8 nation without a public cord blood bank. The Cord Blood Bank will benefit Canadian patients by providing an increased opportunity for transplant and will also reduce Canada’s 100 per cent reliance on internationally sourced cord blood stem cell donations. The Public Cord Blood Bank will consist of five collection hospitals in four cities: Ottawa, Brampton, Edmonton, and Vancouver. In mid-2014 collections will begin at William Osler Health System in Brampton – the hospitals in Vancouver and Edmonton will also be announced. The goal is to bank 20,000 ethnically diverse cord blood units over eight years. To date, 192 cord blood donations have been collected at The Ottawa Hospital.

Dilution of chemotherapy drugs

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On March 20th a pharmacy technician at an Ontario hospital realizes an error in regards to the dilution of chemotherapy drugs. Shortly thereafter, The Ministry of Health and Long Term Care is notified of the dilution and the public is notified. The pre-mixed chemotherapy cocktails were being outsourced from Marchese Hospital Solutions. In total, 1202 patients in Ontario and New Brunswick received diluted chemotherapy drugs, some for as long as a year. Extra saline in the bags of chemotherapy drugs watered down the prescribed concentrations by as much as 10 per cent. One hundred-thirty-seven patients have died since starting their treatment, though there is no indication what, if any, role the diluted medication played. This error revealed a startling problem – health care companies such as Marchese are allowed to mix drugs for hospitals without any oversight – federally or provincially (as reported by Toronto Star). Following an independent review led by prominent pharmacist, Dr. Jake Thiessen,

it was concluded that the diluted therapy drugs “boiled down to gaps in communication,” between the private Marchese Solutions, the hospitals and the bulk drug supply company that brokered the sale of the drugs. Dr. Thiessen said he found no evidence of any harmful intent and made 12 recommendations to improve the oversight of drugs purchased by hospitals. The Ontario government accepted all of the recommendations and introduced the Enhancing Patient Care and Pharmacy Safety Act, 2013 to strengthen the safety and oversight of Ontario's cancer drug supply system. This new legislation, if passed, will allow the Ontario College of Pharmacists to accredit and inspect pharmacies within public and private hospitals, in the same manner it currently accredits and inspects community pharmacies. Health Canada put in place a new policy requiring drug facilities to be regulated under either: the federal Food and Drugs Act, the supervision of a provincially licensed pharmacist, or in a hospital.


Focus 17

Mandatory flu vaccine for health care workers In October, a British Columbia arbitrator upheld a provincial government policy requiring all health care workers in the province to get a flu shot or wear a mask while caring for patients during flu season (December to March). The Health Sciences Association, representing more than 16,000 health science professionals opposed the policy and launched a grievance, and were disappointed with the arbitrator’s ruling.

3500 CT scans and mammograms under review

On September 11th an Ontario hospital issued a public statement that they were in the process of reviewing 3500 CT scans and mammograms conducted between April 1, 2012 and March 31, 2013 to ensure the accuracy of results. The review was being undertaken due to a performance issue with one radiologist who worked at two of the hospital’s three sites. The radiologist who worked at the hospital for 33 years is no longer working there. All patients whose scans were being reviewed were notified. Thus far, the hospital has confirmed that at least one patient was misdiagnosed. The hospital has launched an external review of the scans – led by Dr. Brian Yemen of The Juravinski Hospital and Cancer Centre. In mid -November, Dr. Yemen provided an update: To date, more than 75 per cent of patients have received their results and he is confident he will be able provide his final findings in the coming weeks. The review will be made public.

Many provinces were awaiting the decision in BC and are expected to follow suit in mandating flu vaccines or masks for workers during flu season. Recently, in Ontario, The Ministry of Health and Long Term Care launched the pilot project “Let’s get Fluless”. The campaign, (including posters and information sheets) aims to increase flu shot uptake among health care professionals. Government statistics indicate that Ontario’s provincial median

rate for flu vaccinations among health care workers is between 50 and 60 per cent. For what may be the first time in an Ontario hospital, Bluewater Health has implemented the same policy as British Columbia – all staff, doctors and volunteers are required to have the flu vaccine or wear a mask around patients during flu season. Many other hospitals in Ontario implement this policy, but only during active outbreaks of influenza at their facility.

Anti-vaccination movement: Canada’s immunization rate falling In April 2013 a UNICEF report revealed that the immunization rate for children in Canada is 28th among the world’s 29 richest industrial nations, and is one of only three of the 29 countries in which immunization rates fall below 90 per cent. Canada’s immunization rate has been falling for the last decade. Places in Africa, such as Tunisia and Eritrea, now have higher immunization rates than Canada’s. Vaccination rates are plummeting around the world. Once dormant diseases are reappearing – like measles, one of the most infectious. In April 2013, Ottawa public health officials suspended nearly 1000 students because they did not have properly kept immunization records. They city said that 18,000 warning letters were sent out to parents about providing proof of immuni-

zation or applying for a special exemption. In late October a measles outbreak was reported in Southern Alberta. At press time, 28 cases have been confirmed in the region – most of those infected were not immunized. The first case developed in a boy who travelled to the Netherlands where nearly 2000 people have been infected since May. Southern Alberta has some of the lowest immunization rates in the province -at less than 60 per cent. Alberta Health Services has established mobile immunization clinics in an effort to immunize those who are at risk. Cases of mumps and whooping cough – not common in most developed communities – have also been reported in the region. Seven cases of measles were also reported in the Fraser Health Region (BC) since August – the source has not been found.

The aging tsunami

In 2012 – approximately 21 per cent of Canadians were over the age of 60. By 2030 – it is estimated to rise to 28.5 per cent and by 2050 – 31 per cent. Some experts are warning that the health care system, already strapped for cash will not be able to sustain the increase in demands for healthcare. The Canadian Medical Association’s 13th Annual National Report Card on Health focused on the future of senior’s health care and revealed that a majority of Canadians do not feel confident in the health system’s ability to meet the aging population’s needs. Ninety-three per cent of respondents believe that Canada needs a national strategy for senior’s healthcare at home, hospitals, hospices and long-term care facilities. A Canadian Medical Association survey of almost 10,500 practising physicans indicates that Canada's aging population is already having an impact on medical practice. A survey synopsis says that because of Canada's aging population, it is no surprise that geriatricians (59 per cent) led the list of specialists reporting a major increase in the need for their services.

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18 Focus

Prostate cancer screening:

The debate continues By Dr. Zachary Klinghoffer arly detection of prostate cancer using the prostatespecific antigen (PSA) blood test has remained a controversial topic for several years. The PSA test is often used as a tool to help detect prostate cancer before men develop symptoms, and before the disease has a chance to spread beyond the prostate. Most groups agree that the decision to screen for prostate cancer with the PSA test should be the result of a detailed discussion between a man, his physician, and any others who may help the decision-making process, such as a spouse, family member or friend. Various decision aid tools are available to help with this process. The test cannot provide a definite answer as to whether or not a man has prostate cancer. In general, the higher the number on the PSA test, the higher the chances of having prostate cancer. However, many men with high numbers do not have prostate cancer (this is called a false positive test), while others with low numbers actually do have prostate cancer (this is called a false negative test). Several large studies released within the past five years have suggested that using the PSA test to screen for prostate cancer can reduce the number of men who die from this disease. However, these benefits do not come without risks. These same studies suggest that, in order to save one man’s life, a very large number would have to be screened. Furthermore, some men would be diagnosed with, and potentially treated for, less harmful forms of prostate cancer


Dr. Zachary Klinghoffer is a urologist at Rouge Valley Health System. that may never have had any effect on their lifespans. Numerous medical associations in the U.S. and Canada, such as the U.S. Preventative Services Task Force and the Canadian Urological Association, have taken the results of these studies and interpreted them in different ways. While some take a “men should be screened” or a “men should not be screened” approach, most recognize that the issue is far too complicated to be reduced to a simple “yes” or “no” answer. As long as a man has been provided with the appropriate information and resources he needs to make a well-informed decision, as well as the time and opportunity to ask questions of his physician, the choice he makes about PSA H screening will always be the right one. ■ Dr. Zachary Klinghoffer is a urologist at Rouge Valley Health System.

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From three days to 23 hours: Shortening hospital stay for prostate cancer surgery patients By Kelsi Break wenty years ago patients needing prostate cancer surgery faced a two-week stay in hospital. Today some patients at St. Joseph’s Hospital in London are home within 23 hours, and doing well. In a trial believed to be the first of its kind in Canada, renowned urologist Dr. Stephen Pautler has successfully reduced the length of stay for robot assisted radical prostatectomy (RARP) patients from the current standard of three days to 23 hours, with outpatient surgery being the ultimate goal.


By performing this surgery robotically, carefully selecting candidates based on their physical fitness and following a specific recovery plan, we have safely discharged patients home sooner than ever before

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Prostate cancer survivor Jack Caris has his blood pressure taken by registered nurse Nancy Roberts during his 23 hour recovery stay from surgery at St. Joseph's Health Care London.

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The RARP is a procedure performed using the latest robotic da Vinci Surgical System, a unique platform that allows instruments to be inserted and manipulated through small incision sites, and involves removal of a cancerous prostate gland. “By performing this surgery robotically, carefully selecting candidates based on their

physical fitness and following a specific recovery plan, we have safely discharged patients home sooner than ever before,” says Dr. Pautler. “Patients prefer to recover in the comfort of their own home and with the right support and physiotherapy our patients are having successful outcomes.” Development of this new process was a collaborative effort among St. Joseph’s care team and includes support in the home after surgery through Community Care Access Centre (CCAC). Long-haul truck driver Jack Caris was back behind the wheel within three weeks of his surgery at St. Joseph’s and well enough to take a trip to Europe with his wife soon after. “I hardly had any pain at all,” says Caris. “I had a friend who was diagnosed with prostate cancer around the same time as I was and he had open surgery instead of robotic surgery and it took him eight weeks to recover.” Back on the road and enjoying life, Caris is grateful for the “awesome” care he received from Dr. Pautler, St. Joseph’s staff, and the CCAC. His wife Rose was worried about the short hospital stay at first, “I was concerned when Dr. Pautler said Jack would be home the next day because I knew he would have a catheter for two weeks and I didn’t know how to care for him. Everyone at St. Joseph’s was very kind and explained everything to us really well and CCAC was very H supportive.” ■ Kelsi Break works in communications at St. Joseph’s Hospital, London.


Focus 19

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20 Focus

New toolkit promotes safe infant sleep among

First Nations and Aboriginal families By Lubna Ekramoddoullah B new education toolkit is available in British Columbia to help service providers discuss safe infant sleep practices with First Nations and Aboriginal families and F help h reduce redu the risk of sudden infant death syndrome syyndrome (SIDS). SIDS is i the death of a baby under one year of aage, which is sudden, unexpected, y and without a clear cause. SIDS usuwit ally happens during sleep or napping. ha Although Althou the exact cause(s) of SIDS is unknown, there are clear safe sleep pracunkno tices tthat reduce a baby’s risk for SIDS. A BC B Coroners Service report showed that oover a five-year period, 30 per cent of infants who died in sleep-related in circumstances were Aboriginal, decirc spite spit making up only about eight per cent cen of the infant population. In response, a tripartite working group sp was w formed among the First Nations Health Authority, Government of H Canada, and the Government of C BC to develop a culturally appropriate safe sleep training initiative that could be incorporated into existing programs and services. p


Led by Perinatal Services BC, the working group collaborated with First Nations and Aboriginal Elders, community members, and content experts to develop Honouring Our Babies: Safe Sleep Cards & Guide – an interactive, evidence-informed toolkit that incorporates cultural beliefs, practices, and issues specific to First Nations and Aboriginal communities. The toolkit includes a deck of 21 discussion cards and seven illustrated cards that can be used to prompt and guide discussions with families about safe infant sleep as well as a facilitator’s guide with more information on each card’s topic, research, resources, and graphics. Honouring our Babies: Safe Sleep Cards & Guide can be downloaded from the First Nations Health Authority website at www. under What We Do / Child, Youth and Maternal Health. Perinatal Services BC, an agency of the

Provincial Health Services Authority, provides leadership, support, and coordination for the strategic planning of perinatal services in British Columbia in collaboration with regional health authorities and other key stakeholders. PSBC is the central source in the province for evidence-based perinatal information. For more information, visit The First Nations Health Authority is a health service delivery organization created and mandated to support BC First Nations to implement a number of guiding agreements and documents seeking to elevate BC First Nations health outcomes through the creation a more effective health care system. For more information, visit H ■ Lubna Ekramoddoullah is a Communications Officer with Perinatal Services BC.

Canada’s first Obstetrical Triage Acuity Scale By Kathy Leblanc

ondon Health Sciences Centre (LHSC) has developed a new tool to improve patient care by better managing the triage process for expectant mothers coming into hospital. The Obstetrical Triage Acuity Scale (OTAS) was designed by hospital Obstetrical staff to assist triage nurses in efficiently and consistently determining the severity of a patient’s presenting complaints in an effort to appropriately assess and care for them. “This scale allows us to improve patient care in three important ways,” says Dr. Rob Gratton, Chief of Obstetrics for LHSC. “First, we are able to ensure we are seeing patients based on a standardized assignment of acuity rather than in order of arrival. It also helps us to define the acuity level of our unit at any given time, which helps ensure adequate staffing and resources are in place. And finally, it allows us to measure patient flow and the length of time to care based on acuity.” Last month, the American Journal of Obstetrics and Gynecology published the findings of the reliability and validity of the OTAS acuity assessment tool. OTAS is the first standardized acuity assessment tool designed specifically for pregnancyrelated problems. The OTAS research and design was undertaken by staff from LHSC’s Department of Obstetrics and Gynaecology over a two-and-a-half year period, and included current and future state mapping, presentations to key stake-


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OB nurse Jessica Kershaw reviewing the OTAS tool. holders, staff education sessions as well as an inter-rater reliability study on the tool. The triage acuity scale ranks patients by severity on a scale from one to five, with one being the most urgent priority, and is also used to rate issues such as pregnancy complications and labour developments. “The development and implementation of the OTAS tool has been an incredible undertaking for the entire Obstetrical team at LHSC,” says Laurie Gould, Executive Vice President, Patient Centred Care. “In particular, the nursing staff in the Obstetrical Care Unit has played a vital role in the tool’s success. We are excited about the benefits this tool will continue to have for our patients at LHSC and beyond, as we share it with hospitals H in our region and across the country.” ■ Kathy Leblanc is a Communications Consultant at London Health Sciences Centre.


Focus 21

New data suggests important

improvements in infant and maternal health By Mari Teitelbaum ince BORN was formed in 2009, health care providers and decision makers now have improved tools to continue working together to collect and use data about the health of infants and mothers in Ontario. This data has led to important changes in health care practices, outcomes, and policy decisions. At the same time, the data is providing a snapshot into the overall health of Ontario and the areas where improvements are still needed. Recently, the Better Outcomes Registry & Network (BORN Ontario) released a report containing health data and practice highlights ranging from prenatal screening rates to breastfeeding practices… and everything in between. The report shows improvements in exclusive breastfeeding rates and a reduction in women who smoked during pregnancy. Meanwhile, work is still needed to adjust the timing of repeat c-sections for low-risk women and inductions in overdue women.


Among the report’s highlights

•Maternal age: 56.4 per cent of women who gave birth were 30 years of age or older. The largest proportion of births was to women between the ages of 30 and 34 (34.3%). During the same period, three per cent of births were to women 19 years of age and under, while 22 per cent were to women 35 years of age and over. •Prenatal screening: the proportion of pregnant women who had prenatal screening rose to 68.4 per cent up from 68.2 in 2010–2011 and 66.9 in 2009–2010. •First time mothers: 43.3 per cent of women who gave birth were first time mothers. •Smoking: the percentage of women who reported smoking during pregnancy at 20 weeks’ gestation or later declined, standing at nine per cent in 2011–2012 down from 9.7 in 2010–2011 and 10.2 in 2009–2010. •Regional anesthesia: 63.4 per cent of women used some form of regional anesthesia for pain management during labour. •Cesarean sections: C-section rates were stable over the five year period from 2007– 2008 to 2011–2012 at approximately 28. per cent. Specifically related to elective repeat C-sections performed prior to 39 weeks’ gestation among low-risk women, BORN has developed an audit and feedback tool (the Maternal Newborn Dashboard) to help hospitals monitor their performance and reduce rates. The quarterly rates have been reduced from 54.6 per cent, prior to launch of the dashboard, to 44 for May 1 to July 31, 2013, but are still much higher than the target benchmark value of 11 per cent or less. •Induction rates: another indicator from the BORN Maternal Newborn Dashboard focuses on reducing inductions performed too early when the woman wasn’t actually past 41 weeks gestation. This proportion was reduced from 24.7 per cent prior to

launch of the dashboard to 20.1, but is still higher than the benchmark. •Breastfeeding: exclusive breastfeeding is an important determinant of neonatal and infant health and is associated with reducing childhood obesity. The rate of exclusive breastfeeding at discharge among term live births in Ontario increased to 63.2 per cent in 2011-2012, up from 61.6 in 2009-2010 and 59.8 in 2007-2008.

The data collected and made available through BORN Ontario is quickly finding its way to the centre of Ontario’s health care system.

How hospitals and health providers are using BORN Data

We know that our lifelong health trajectory is influenced by what happens in the first few days, weeks, and months of our lives. This period is often as important as what we do throughout our lifetime. It is for this reason that the data collected and made available through BORN Ontario is quickly finding its way to the centre of Ontario’s health care system. Our collective investments in quality data has a real impact and helps to ensure newborns have the best possible start and opportunity for a healthy future. Over the last year, Ontario’s hospitals have been particularly successful at using the data to improve their practices and outcomes. For example, the Markham Stouffville Hospital has been working to reduce the number of c-sections among low-risk women, ensuring that the procedure occurs only when necessary. Using BORN data, the hospital was able to track their own information step-by-step to determine that high rates resulted from, in part, their induction practices. Armed with this information, the hospital revised its induction procedures and successfully reduced the number of c-sections performed in their hospital. In another hospital, BORN Ontario data was also key in a pilot program to improve care and reduce costs by keeping more mothers and newborns together after birth rather than separating the newborn in a neonatal intensive care unit. The data was also successfully used to monitor and reduce the number of unsatisfactory newborn screens for rare genetic diseases from 16 per cent to seven per cent in one hospital, thus reducing repeat tests and return visits. The quality of the data depends on all of us working together. At BORN Ontario, we are privileged to have a variety of partners as we collect data from fertility clinics, midwifery practices, prenatal and newborn screening labs, follow up clinics, and hospitals. Collecting data from such a wide range of stakeholders allows for a more complete picture of maternal child health in Ontario. To learn more about how you can use BORN data, please contact us or visit our H website ( ■ Mari Teitelbaum is the Director of BORN Ontario. DECEMBER 2013 HOSPITAL NEWS


22 Focus

Minding the gaps in quality improvement in

Canadian healthcare By John G. Abbott hat can Canada gain by upping its investment to advance the health quality improvement (QI) agenda? And, in what areas should it invest? A lot, in my opinion; and the focus needs to be on increasing the capability and capacity of our system and its leaders to deliver transformative change. On October 29 and 30, 2013, the Health Council of Canada hosted a National Symposium on Quality Improvement – Towards a High Performing Health Care System: The Role of Canada’s Quality Councils. The forum provided an opportunity for 200 senior leaders from across Canada to discuss health system performance measurement and reporting, as well as the need to build capacity and capability for quality improvement. The symposium highlighted the work of the provincial health quality and patient safety agencies in these respective areas, and explored opportunities for further inter-provincial collaboration on quality improvement. The event stressed the need to increasingly think and act as one, if we [Canada] want to optimize the quality of health care for all Canadians. It was clear from discussions that there is no ‘one size fits all' when it comes to performance measurement or reporting and each jurisdiction with a quality and/or patient safety organization (there are seven in total) have adopted approaches that are working for them. So what are the gaps in Canada’s current quality improvement approach that need to be closed? And how do we achieve transformative change?


The first gap is the absence of a burning platform for transformative change so that quality improveIf individual hospitals or ment is embedded in organizations continue to look everything we do in h healthcare. Are health only at their own performance, ns leaders and Canadians quality improvement will ced themselves convinced remain fragmented that we need to improvee the ng dequality of the care being l, clinic and livered in each hospital, doctor’s office in this country? The evih enough h objective? If QI is its own silo, we are not dence says we need to, bbut is that to make the case? going to achieve transformative change in The second gap or challenge is treat- any setting. ing QI as an add-on. Shouldn’t our health Dr. Jack Kitts, Chair of the Health system encourage all its leaders to begin Council of Canada and CEO of the Ottatheir day with the question: What have wa Hospital is leading a collaborative iniwe got to do today to ensure all our activi- tiative involving 12 of Canada’s teaching ties deliver safe and appropriate care for hospitals to narrow down indicators for our patients; and end their day by asking: safe and appropriate care, among other how do we know that we achieved this activities related to quality care. Accord-

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ing to Dr. Kitts, “If individual hospitals or organizations continue to look only at their own performance, quality improvement will remain fragmented. In this collaborative, we are working to reach agreement on a select number of indicators that we will report publicly. These indicators will not only allow the public to assess the performance of individual hospitals, they will allow us to compare performance across Canada, and learn from each other in the process. Joining forces like this is just a start to putting QI into the arena of transformative change. While it is still a work-in-progress, I am learning that identifying where you want your system to go and getting there are two different things. One thing is clear: without leadership and a commitment to improvement we won’t get there.” The third gap relates to resources. We need to increase the level of investment in resources to successfully design and manage a QI agenda. We need to train people at the front lines and in the back rooms to think as one, using a common language around performance improvement. We need to continually support the work of quality councils in this country who in turn are aligning their activities in support of the health systems that they both monitor and engage on quality improvement initiatives. A fourth gap is not appreciating the magnitude of managing complex system change. Several provinces have recently launched new initiatives to equip front line staff and leaders with the skills to manage complex changes across the system. I draw on Saskatchewan as likely the most advanced example of system-wide change management. The government and the Health Quality Council of Saskatchewan have committed to ensuring every one of the 40,000 people who work in health care there has at least one day of Kaizen training. In Saskatchewan, this has taken QI ‘off the side of the desk’ and put it squarely on everyone’s agenda. A fifth gap lies in the area of technology and information sharing. We need to leverage the use of today’s technology to collect data and share information about system performance and patient outcomes in a consistent and timely way that can be used by all parts of the system to improve the quality of care. No one organization or system has all the answers to addressing these gaps. All in all, we need to collaborate within and across organizations and jurisdictions to build capacity and capability in all these areas. The Health Council’s report on the proceedings of its event will cover these points in greater detail and will be released on December 16, 2013 at www. H ■ John G. Abbott is the Chief Executive Officer, Health Council of Canada.




Focus 23

‘Tumour biobank’ brings breast cancer discoveries to the bedside more quickly By Dahlia Reich n a move to fast track discoveries in breast cancer diagnosis, treatment and prevention from the lab to the bedside, Dr. Muriel Brackstone, a surgical oncologist with St. Joseph’s Breast Care Program, has developed London’s first breast ‘tumour biobank’. Patients coming to St. Joseph’s Hospital for a biopsy to diagnose a potential cancer are being asked if they would donate a small fragment of the lump for this biobank, explains Dr. Brackstone, medical director, breast surgery at St. Joseph’s and a scientist with Lawson Health Research Institute. About 10 breast biopsies are performed each day at St. Joseph’s and, to date, 93 per cent of patients have opted to donate. “Information about any cancers diagnosed in these generous women will be stored to provide scientists with valuable clinical data on how these tumours behave in order to figure out how to outsmart them,” explains Dr. Brackstone. London is fortunate to have a large number of scientists with diverse expertise working at research and academic centres across the city to better understand breast cancer and ultimately eradicate it. They are looking at how breast cancer develops and spreads, improved imaging and surgical methods, which patients require chemotherapy and which don’t, testing to predict if the cancer is at risk of returning, and much more. “What they lack is access to patient tumour samples and blood in order to test their theories, develop their imaging tools and create new treatments. The goal is to overcome that obstacle, allowing these scientists, together with oncologists, to translate discoveries in the lab into real discoveries in months instead of years,” she adds. Barbara Rocco was diagnosed with breast cancer in July, underwent a mastectomy in September, and is now awaiting chemotherapy. She didn’t hesitate when asked if she would donate a sample at the time of her biopsy. “I have two daughters, three granddaughters and one daughter-in-law,” says Barbara. “Donating a sample was an opportunity to give to research that may someday benefit not only them but all women. It’s


Tumour biobank – facts and stats •The tumour biobank allows for the preservation and storage of samples of tumours. •It is a liquid nitrogen freezer, also known as a cryogenic freezer; that stores samples at -200 degrees Celsius to keep them perfectly pristine. •The St. Joseph’s tumour biobank can hold 48,000 patient samples. It can be used to store any type of tumour sample and made available to scientists doing any type of cancer research. •The tumour biobank and collection of pre-treatment tumour samples allows for new directions in clinical research. •The St. Joseph’s tumour bank is currently being accessed by scientists at research.

The tumour biobank is being housed in the Lawson Health Research Institute lab of Dr. Muriel Brackstone (centre) a surgical oncologist with the Breast Care Program at St. Joseph's Hospital in London and a scientist with Lawson. She is seen here with Kalan Lynn, research coordinator for the tumour biobank, and Dr. David Hill, scientific director of Lawson. research that will lead to better treatments, better diagnostics and better quality of life for women as they go through this process.” The breast tumour biobank is being housed in the Lawson Health Research Institute through which all hospital research is conducted. “We have never had an onsite tissue bank at St. Joseph’s Hospital,” says Dr. David Hill, Lawson scientific director and integrated vice president of research at St. Joseph’s and London Health Sciences Centre. “This will be an important resource to advance cancer research and

will provide a valuable facility to advance other areas of research also.” London’s breast tumor biobank is a stand out in Canada and internationally for the systematic way in which every patient with suspected breast cancer is offered an opportunity to donate tissue at the time of their biopsy, explains Dr. Brackstone. “This saves them having to go back for a separate biopsy procedure. It also allows newly diagnosed breast cancer patients the option of taking part in innovative pre-operative clinical trials – before their cancer surgery – that are not

typically available elsewhere in Canada.” Patients are eager to donate despite what they are going through, adds Dr. Brackstone. “Taking part in research empowers patients.” The tumour biobank is one of many initiatives of St. Joseph’s Breast Care Program focused on the forefront of innovation and treating patients with compasH sionate clinical excellence. ■ Dahlia Reich works in Communication & Public Affairs at St. Joseph's Health Care, London.

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24 Focus

Labour and birth information from BC hospitals made available to public By Lubna Ekramoddoullah abour and birth information for each hospital in British Columbia is now available to expectant mothers, their families, the general public, and health care providers. Perinatal Services BC (PSBC), an agency of the Provincial Health Services Authority, has provided this information on its website to help maternity care providers continue to improve care and support the best outcomes for mothers and babies. Perinatal Services BC provides leadership, support, and coordination for the strategic planning of perinatal services in British Columbia in collaboration with regional health authorities and other key stakeholders. PSBC is the central source in the province for comprehensive, evidence-based perinatal information, which it collects through the BC Perinatal Data Registry, a database containing clinical information on all births collected from hospitals and registered midwives who attend births at home. PSBC selected five indicators that are: important to the health and wellbeing of mothers and babies; based on solid evidence that supports the best approach to care; and measurable.


The five indicators are:

1. vaginal delivery for first-time mothers; 2. repeat cesarean section before 39 weeks (early term); 3. post-date induction before 41 weeks; 4. exclusive use of intermittent auscultation (listening to fetal heart beats at specified intervals) during labour; and 5. babies who were breastfed from birth to discharge. BC is the first province in Canada to make perinatal data at the hospital-level available to the public. The information can help keep expectant mothers better informed about the health services they receive, have informed conversations with their doctors, midwives, or nurse practitioners about their labour and delivery options, and help them prepare for their birth experience.

“The women of British Columbia and their families are lucky to enjoy such a wide spectrum of maternity services throughout the province,” says Dr. Geoffrey Cundiff, Professor & Head, Obstetrics & Gynaecology, University of British Columbia. “Perinatal Services BC has collected data on performance of the maternity providers and reported it back to the units for some time, and this has been essential to maximizing the quality of care at all sites. Making this information available to the public is the logical expansion of this approach. It is important to recognize how differences between sites and the populations they serve will influence the indicators. Nevertheless, they provide an excellent method for patients to open a conversation about quality and expectations with their maternity providers.” Health care teams can use this information to continue to improve quality and safety within perinatal care across the province. “We are pleased to be working in partnership with health authorities,” says Kim Williams, Provincial Executive Director, Perinatal Services BC. “By using best evidence and looking at the trends, PSBC supports health authorities and care providers in delivering the best care they can to women, newborns, and families. We can learn from one another, share best practices in maternity care, and identify areas for change or improvement. This is an exciting opportunity to make a difference in the lives of women and their families in BC by optimizing maternal and newborn health.” Working together, Perinatal Services BC and regional health authorities strive to provide the best in perinatal care for women and their newborns across the province. For more information, or to access the data, visit the Surveillance section of www.perinatalH ■ Lubna Ekramoddoullah is a Communications Officer at Perinatal Services BC.

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Members of the Breast Care Program at St. Joseph's Hospital in London model the new gowns specially designed for breast care patients.

Designer gown custom-made for breast care patients By Dahlia Reich t’s a designer gown that will never make it to the runway but is a big hit at St. Joseph’s Hospital in London. Inspired by patients and staff, the fine details are dignity, comfort and versatility, making this one-of-a kind hospital gown haute couture in the Breast Care Centre. The new hospital gown, made specifically for breast care patients, was a collaborative effort of St. Joseph’s Health Care London and London Hospital Linen Service (LHLS). After looking at existing products and finding they didn’t fit the needs of both patients and the hospital, the two organizations sat down at the drawing board. The goal was a one-size-fits-all gown that was comfortable, respectful and user friendly for patients, functional for both surgery consults and breast imaging, and could hold up to repeated laundering without increasing the hospital’s laundering costs. After months of testing various prototypes and gathering feedback from staff and patients, the final concept went into production. Designed to be worn two different ways to accommodate both mammography and ultrasound scans as well as exams by surgeons, the new gowns are now in use and receiving rave reviews, says Howard Hansford, Site Leader, Diagnostic Imaging Centre at St. Joseph’s. LHLS, which donated much time and expertise on the project and worked with Lac-Mac Ltd. in London to manufacture the gown, “was exceptionally attentive and responsive to our patient needs,” adds Hansford. “There were many tweaks over several months.”


The bathrobe-style gowns are thicker than the usual hospital garb, explains Pauline Bessegato, Coordinator, breast surgery. “Denim blue in colour with a pink trim, they are also much more attractive and add a spa-like touch for patients who may be feeling stressed and anxious.”

The goal was a one-sizefits-all gown that was comfortable, respectful and user friendly for patients, functional for both, surgery consults and breast imaging “St. Joseph’s has always been a key partner of LHLS and we want to help the hospital in its mission of care,” says Brendan O’Neill, Manager, Corporate Development, LHLS. “It was such a great opportunity for us to work with patients and staff and produce something that we could potentially bring to all our customers.” About 560 gowns are used at the Breast Care Centre each week. LHLS is hoping to add the innovative design to its product line so that it’s available to hospitals across Southwestern Ontario. Adorned with patient-centred care, the custom gowns may H well become a classic. ■ Dahlia Reich works in Communications at St. Joseph’s Health Care, London.

Nursing Pulse 25

Finding a balance between “hard” and “soft” nursing skills By Rhonda SeidmanCarlson

ince becoming president of the Registered Nurses’ Association of Ontario (RNAO), I have had the great privilege and opportunity to meet with many nursing colleagues across Ontario and Canada. I have learned from each encounter what works well for nurses, and what does not. I have paid close attention to the language used by nurses and by those talking about nurses and the profession. It has been said that language communicates more than content. The words we use can serve to elevate a group of people or further isolate them. Language in nursing can also enlighten or obscure matters of importance. There are many expressions I have heard in my travels, and in this column, I want to explore the notion of “soft knowledge and skills” in nursing, an expression I have heard frequently when it comes to describing nursing practice. Usually this refers to the emotional, social and psychological aspects of the profession. Is this how we should characterize this side of nursing? Or should we, as registered nurses, challenge this term? Let’s focus on the other side of the coin first. “Hard knowledge and skills” are those that can be measured. For example, the pathophysiology a nurse needs to master, and the psychomotor skills a new nurse must learn. This hard knowledge and skill is important and tangible, and patients benefit from it. The risk here is that if we only focus on hard knowledge and skills, and only measure these, we are robbing patients and our profession of the humanity of nursing care. For me, hard knowledge and skill captures one side of the nursing profession: its scientific side. The other side is the moral fabric of the profession, or its ethos. Let us not forget that nursing is a caring and service profession, and this must encompass science, art and morality. As I have noted, soft knowledge and skills are the emotional, spiritual and caring aspects of the profession. These are harder to measure, but no less important and valued. In fact, I would argue they are critically important to patients and their families during their time in the health system. To say these are soft can be viewed in interesting ways. Are they soft because they are perceived as a female trait, an innate part of being a woman and not necessarily guided in evidence and research? Are they soft because they are “airy fairy” and less valuable to the health-care field? If these skills are seen as not evidence-based, or perceived as less essential, then it becomes easier to ignore them when making decisions on how best to utilize nursing professionals in an ever-challenged fiscal environment. So what can we do so these soft elements of nursing practice are regarded as equal in value to the hard and measurable aspects of the profession? I would urge all nurses – myself included – to watch our language. And I would urge patients to do the same. Do not speak of these elements of practice as soft skills. Talk about them as core skills and knowledge in nursing. When someone speaks of the soft


skills, ask them to explain what they mean. Do they value them less because they are more difficult to measure? I believe the discussion itself will begin to change the meaning of the language. In addition, we need to highlight the outcomes in patient care, patient satisfaction and nurse satisfaction when nurses apply these core skills in their practice. Each nurse needs to have time in their day to be with patients, time to connect with the

emotional and spiritual needs of patients and their families. This is as critical to positive outcomes as administering medications and providing treatment. I urge all nurses to use the evidence that currently exists to describe the outcomes of using emotions, spirituality and caring interventions when working with patients and their families. Challenge the notion that these are softer skills, and make the case this is part-and-parcel of what nurs-

ing is. It is the essence of the profession and represents a key element of the important role nurses play on any health-care team. If we forget this, we risk losing the real H value-added of nursing. ■ Rhonda Seidman-Carlson is president of the Registered Nurses’ Association of Ontario (RNAO). This column was originally published in the September/October 2013 issue of Registered Nurse Journal

“No doubt about it. A permanent spinal cord injury will depress you... but you have to work through it and realize that life goes on and still has a lot of wonderful surprises for you.” – Frank Nunnaro

Frank Nunnaro is a regular guy with a real talent for barbecue cooking. He was a produce manager at an Orillia IGA when he had a terrible car accident that damaged his spinal cord and left him a paraplegic. After intensive rehabilitation at Lyndhurst Hospital, and with the loving help from his wife Vicky, Frank has gone on to become one of the great BBQ hosts of the century. Every year in the middle of the summer, Frank and Vicky host an amazing barbeque party at their Wasaga Beach home. Frank likes to think of it as a real celebration of life. We like to think of it as a testimony to the human spirit. We are honoured to have represented Frank Nunnaro in his lawsuit and to count Frank as a friend and one of the many everyday heroes we have been able to help.

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26 Care Giving

Pivotal eldercare year closes By Bart Mindszenthy n many ways, 2013 will be remembered as a pivotal year in the evolution of the brave new world of eldercare in the family. In Canada, this year marked the start of a more open discussion of the moral and ethical implications of assisted suicide for the willing aging and ill. It marked the Supreme Court of Canada ruling that a family’s decision to maintain it’s ill loved one on life support trumps the verdict of health care experts. This year saw more media attention to the challenges families face in offering care and attention to the aging elderly. As well, during 2013 we saw more reports of violence in nursing homes: elderly attacking elderly, suggesting cognitive issues not yet really defined, not to mention questions of safety standards in nursing homes across the country. Globally, the Canadian experience is being repeated over and over most everywhere. Perhaps its being most strongly felt in China and Japan where the aging population can no longer count on the sustained support of their children


and grandchildren who are moving away from the traditional family home to find better jobs and brighter lifestyles.

Strikes close to home

Personally, this past year I’ve been in some way or shape engaged in a host of situations experienced by many friends involving some aspect of family care and resulting pressures and conflicts. Here are four examples: •A couple with a son who returned home six months ago ‘for just a few weeks’ after losing his job and with no firm new prospect while concurrently looking after three aging and frail parents and all the while still both working full time. They are struggling to make ends meet and keep getting up five days a week to long, long work days. They don’t know where all this leads; they’re too loving to challenge their son to be more proactive in getting back on his feet, and too loving to find better solutions to eldercare. •A 71 year old bachelor with a 94 year old ailing mother who still lives alone in a tiny apartment and is suffering from severe arthritis and mild diabetes; they live

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in the same region but he’s an hour’s drive away while expected to visit at least four or five times a week. And because both are strapped financially, he feels compelled to come help her, clean her apartment, and of course has to run errands for her and take her for doctor’s appointments. Problem is, while he’s in relatively good health, he’s got little time left to live his own life.

Now we share the enormous challenge of finding better and more ways to care for the elderly in humane and responsible ways. •A couple in their early sixties in Toronto with both sets of parents still alive: one set in their early eighties and one in their latter eighties. What complicates their lives and stretches their resources is that her parents live in Kamloops and his in Halifax. Trying to provide long distance loving attention to both sets of parents is becoming ever more difficult and expensive for them. They have committed to at least annual visits to each set of parents and have been working on finding local support resources to help out. •A friend in his mid seventies whose wife has been diagnosed with early stage Alzheimer’s and has lost her driving license while they still need to find ways to support her 94 year old mother in a close by HEALTH RESTORATION PROGRAM FOR HEALTH CARE PROVIDERS


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nursing home who demands a lot of time and attention. He is starting to fray at the edges as he juggles his wife’s expanding needs, his mother-in-law’s continuing needs, his relations with his children and grandchildren, and the need for time for himself.

The common denominator

What all these friends and acquaintances share is the element of an aging and ever more needy parent. And it’s what growing numbers of Canadians are experiencing. More than four million of them, in fact. And hundreds of millions more worldwide. It’s what’s come from being hidden on the back streets of society to finally blasting onto main street: the monumental range of issues and challenges of eldercare in the family. We’re all listening now, experiencing it, starting to share it, finally learning how to deal with it. The warning signs have been there for more than a decade, but we’ve elected to ignore them. Now we don’t have a choice. Now we share the enormous challenge of finding better and more ways to care for the elderly in humane and responsible ways. It’s not easy. And that’s been a major lesson this year. In my last column I focused on my new co-authored book, Parenting Your Parents: Straight Talk about Aging in the Family. Actually, it’s pretty easy. You just have to subscribe for a digital subscription of Hospital News with your email address. Five copies are to be awarded. Please enter. It’s a really good book, even if I say so. And I say so with some pride because the publisher just advised my co-author, Dr. Michael Gordon, and me that we’re about to go into a second printing just two months after the book appeared on the market. How sweet is that? And in closing for this column, I wish you and your loved ones the best of health H and happiness for the coming year. ■ Bart Mindszenthy, APR, FCPRS, LM, is co-author of the Parenting Your Parents series of books; to read more, visit He is a best-selling author on the issues and challenges of caregiving in the family as well as other topics; see www.famliyeldercareworkbook. ca. His column on caregiving appears quarterly in Hospital News.


Focus 27

Identifying the care needs of women living with HIV By Angela Kaida he face of HIV has changed dramatically from the early days of the epidemic. Women now comprise more than half of all people living with HIV around the world. In Canada, an estimated 16,600 women are living with HIV/AIDS out of an estimated 71,300 HIV-positive Canadians. Women also represent an increasing proportion of annual positive HIV test reports, accounting for 23 per cent of the Canada total in 2011, nearly double the proportion observed in 1999 (12 per cent). Despite the changing epidemiology of HIV in Canada and globally, relatively limited research has focused on health issues specific to women living with HIV. The increasing burden of HIV/AIDS on Canadaâ&#x20AC;&#x2122;s female population is deeply concerning. We know that women face greater biological susceptibility to HIV. Women also face increased vulnerability due to prevailing social inequities including poverty, violence and racial marginalization. Providing all people living with HIV with appropriate and timely treatment and care is critical to reduce HIV-related morbidity, mortality, and new HIV transmissions. However, women continue to face unique barriers to accessing treatment and care and show poorer outcomes. Itâ&#x20AC;&#x2122;s therefore


critical that we gain a better understanding of the needs of women living with HIV. In an effort to acknowledge and address the gendered barriers to HIV treatment and care for Canadian women, our national team of researchers, clinicians, service providers, policy-makers, and women living with HIV collaborated to develop the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS).

Women now comprise more than half of all people living with HIV around the world. After two years of groundwork, CHIWOS was officially launched on October 1, 2013, the start of Womenâ&#x20AC;&#x2122;s Health Awareness Month. The CHIWOS study will help identify gender-appropriate approaches necessary to support the delivery of comprehensive and high-quality HIV care that more fully meets the needs of women. Supported by the Canadian Institutes of Health Research (CIHR) Institute of Gender and Health, CIHR Canadian HIV Trials Network (CTN 262) and the Ontario HIV Treatment Network (OHTN), CHIWOS is the countryâ&#x20AC;&#x2122;s largest multi-site, longitudinal,

community-based research study focusing solely on women living with HIV. In collaboration with a National Steering Committee, three provincial Community Advisory Boards, and a national Aboriginal Advisory Board, the study brings together a rich diversity of perspectives and specialties from across the country. The study involves women living with HIV in all stages of the research, from the conceptualization and design of the study, to the survey development process, to the collection and analysis of the data. For far too long, womenâ&#x20AC;&#x2122;s HIV care needs have been overlooked. We have engaged in this research with strong community input and hope that women living with HIV will be encouraged to participate, so that their voices and priorities will be heard. Researchers will recruit and enroll over 1,250 women living with HIV in British Columbia, Ontario, and Quebec â&#x20AC;&#x201C; the three Canadian provinces with the largest number of women living with HIV. Across Canada, 34 Peer Research Associates (PRA), themselves women living with HIV, have been hired and have undergone intensive training in research methods, interview techniques, and self care. PRAs have begun administering surveys to eligible participants: people 16 years or older, who identify as women, are living with HIV, and residing in BC, Ontario, or Quebec.

Study participants are asked to complete a questionnaire at baseline with a follow-up interview 18 months later. Interviews are taking place at multiple clinics, AIDS service organizations, and other communitybased organizations across the three study provinces. Study results will be released in early 2015. Since the official study launch, the response from the community has been electric. Our phones and inboxes have been filled with messages from women who are eager to contribute their stories to the study. Their input has the potential to change HIV care for women in this country and around the world. As Valerie Nicholson, a peer researcher for the study said: â&#x20AC;&#x153;This study is giving a voice to women who previously had no voice. My hope is this research will ensure the women in my community, and our children and grandchildren, donâ&#x20AC;&#x2122;t have to face the same barriers to care I have experienced in my lifetime.â&#x20AC;? For more information, including how to participate in the study, please visit our H website at â&#x2013; Angela Kaida is an Assistant Professor and Canada Research Chair (Tier II) in the Faculty of Health Sciences, Simon Fraser University. She is the Principal Investigator for CHIWOS in British Columbia.




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28 Focus

A decade of the Common Drug Review By Sarah Berglas ithin the health care arena, how many examples of federal, provincial and territorial collaboration can you name? How many have endured for over a decade? One such example is the The Canadian Agency for Drugs and Technologies in Health (CADTH) Common Drug Review. For a new prescription drug to be sold in Canada, it must first be reviewed by Health Canada to ensure that it meets Canadian standards for efficacy, safety and quality of manufacturing. The next step is to consider the relative benefits, safety and costeffectiveness of this new drug compared to existing treatment options. This is where the CADTH Common Drug Review fits. On behalf of 18 publicly funded drug plans, the CADTH Common Drug Review has been answering the question of how a new drug compares to existing therapies for more than 10 years.



How does the process work? All publicly funded drug plans (except Quebec), cooperated to build, improve and fund the CADTH Common Drug Review. If a pharmaceutical or biotech company wants their drug to be considered for inclusion on the publicly funded drug plans formulary, they submit all relevant clinical and economic information to CADTH for review. Patient groups are invited to provide input to identify unmet needs of existing options


and treatment outcomes of greatest importance to patients. A review team made up of epidemiologists, pharmacists, physicians, health economists, information specialists and at least one external physician with specialist expertise in the relevant clinical area, prepare a systematic review of the clinical evidence and a critique of the drug sponsor’s economic evaluation. External experts of methodology help ensure the analysis is of the highest quality and the most appropriate techniques are used. The reports produced by the review team are discussed by the Canadian Drug Expert Committee (CDEC), comprised of highly

qualified health care experts and public members from across Canada, who provide advice and formulary listing recommendations. Each of the 18 publicly funded drug plans then uses this information to make their jurisdictional listing decision. The reasons behind CDEC’s recommendations are publicly available, and one may track the progress of new drugs moving through the review process ( Since 2003, 72 different pharmaceutical companies have used the CADTH Common Drug Review process and 264 recommendations for publicly funded drug plans have been made. The CADTH Common Drug Review continues to evolve and improve. Transparency enhancements and patient engagement (through a patient group input process) are just some of the initiatives that CADTH has recently introduced.

Contribution by specialists

The diversity of drugs being examined during any period is vast. For example, right now, CADTH is reviewing drugs to manage chronic obstructive pulmonary disease, heart failure, ulcerative colitis, schizophrenia, vitreomacular adhesion, chronic migraine, Parkinson’s disease, growth hormone deficiency in adults and children, Turner’s Syndrome, and polyarticular juvenile idiopathic arthritis. To be able to identify relevant comparators and fully appreciate the clinical considerations in these diverse fields, CADTH is tremen-

dously grateful to the all external experts who participate on each team. CADTH is also grateful to patient groups, who share lived experience; and to the pharmaceutical and biotech companies who submit all relevant clinical and economic information on their drugs for review. Every drug reviewed enlists the support of one or more clinical experts. Experts in the fields of health economics or review methodology are invited to participate as required. If you are interested in becoming involved, please contact CADTH. For more information on CADTH and the CADTH Common Drug Review, visit H our website: ■ Sarah Berglas is a Knowledge Mobilization Officer at The Canadian Agency for Drugs and Technologies in Health. Hospital based clinicians While a patient is in hospital, the question of whether a prescribed drug will be covered under their insurance plan isn’t an issue; however, it can become one at discharge. It is always a consideration for patients treated in the community. Hospital pharmacists can offer guidance as to which medicines are most cost-effective and can identify drug options listed on the publicly funded formularies.

From the CEO's Desk 29

Forty years and counting By Murray T. Martin

y health care career began on April 26, 1971 as the Assistant Administrator of Swift Current Union Hospital in Swift Current, Saskatchewan. Considering the financial challenges the health care system is experiencing today, itâ&#x20AC;&#x2122;s ironic that I owe that first job to the fact that the hospital was running a deficit and the administrator was told to hire an assistant. Still, as I look back on my 43 years as a health care system leader, I count myself lucky to have had the incredible opportunity to be associated with so very many outstanding people, and to bear witness to their remarkable levels of ability and commitment to patients.


In order to be sustainable, our hospitals will need to be resourceful and versatile in establishing new approaches to care that meet the changing needs of our patients, and of society in general. I recall an era when it would have been unethical to perform open heart surgery on an individual over the age of 70. Today, it is the exception when the same surgery is performed on a patient under the age of 70. And surgery is just one field that has been transformed by the introduction of new technology. Medical research has led to many other advances, including customized pharmaceuticals and gene therapy â&#x20AC;&#x201C; two innovations that have great potential for radical change and improvement in medical care. With the promise of so many breakthroughs now on the horizon, never in history has there been a better time to require care. All of this has had a profound effect on the role of hospitals, and will continue to impact the work we do in the future. In order to be sustainable, our hospitals will need to be resourceful and versatile in establishing new approaches to care that meet the changing needs of our patients, and of society in general. The real questions that will require answers as we establish priorities for our health care system of the future include: â&#x20AC;&#x153; What can we do as enabled by technology?â&#x20AC;?, â&#x20AC;&#x153; What should we do when it comes to making difficult, ethical decisions such as end-of-life care?â&#x20AC;?, and â&#x20AC;&#x153; What can we afford to do as driven by our financial reality?â&#x20AC;? Very soon we will be nearing the gorge between the ability of our publically funded health system to provide services, and what taxpayers can afford to pay. Of course, there is always the public policy choice of going to higher levels of taxation to increase our capacity to pay. This would obviously be a very unattractive option that should only be pursued after we have (a) removed the maximum amount of wastage from expenditures on

ue-added costs in health care delivery, and (b) optimized efficiency. We have a great deal of work to do in the elimination of such practices as the unnecessary use of antibiotics, diagnostic services, consultations, hospitalizations and ambulatory visits. These savings need to be identified, harvested and then directed towards supporting the growing costs of effective, evidence-based therapies. Tackling this issue may require a fundamental realignment of incentives amongst providers, and that will require considerable political stamina to garner the needed public support. Over the years, voices for change have fallen to deaf ears when politically sensitive topics such as the over professionalization of care delivery are brought to the table. The health care provider lobby looking out for the interests of professional groups has been very successful at protecting the status quo on behalf of its members. Governments have been timid in their attempts to move forward with changes in legislation and/or regulations that would be required to change scope of practice. There is a real fear of a backlash from professional groups whose economic interest may be threatened. How, as a society, can we deal with the power of the health care lobby? Or do we even want to deal with it? We know that the labour input costs for most health care providers in North America are at least 30 per cent higher than Western Europe. Perhaps the public does see value in paying higher levels of compensation in order to have access to highly trained and committed health care professionals. But does this then lead us right back to the need to pay higher taxes? What level of compensation can the public today afford to pay? I have painted a rather bleak picture of the future ahead, but I do want to finish with a few notes of optimism. I have had the privilege of serving as CEO of two of Canadaâ&#x20AC;&#x2122;s outstanding research hospitals â&#x20AC;&#x201C; a total of 23 years at Vancouver Hospital and Hamilton Health Sciences. In those roles, I have been exposed to the leading edge of what lies ahead in health care delivery. I know that Canadaâ&#x20AC;&#x2122;s research hospitals are rapidly moving towards standardization of best practice as an effective way to achieve higher quality and reduce costs. Evidence-based practice is now part of the everyday ethos of decision making. In addition to care delivery, research hospitals are also positioned to play a societal leadership role in dealing with major issues such as futile, expensive, end-of-life care, and the sensitive issue of end-of-life choices. Investment in health research makes Canada healthier, wealthier and smarter. Research hospitals, along with their community partners, will be leaders in determining the most effective way to keep people out of hospital through advancing prevention and providing communitybased support. However, to reap the full rewards of research advances, innovation

Murray T. Martin is President and CEO of Hamilton Health Sciences. needs to be paired with investment and the political will to make choices that will help sustain our system. I will end my career this coming year knowing that our system has immense ability to rise to meet the challenges that each new decade brings. My joy as an ad-

ministrator has been largely driven by the wonderful people I have worked with and the incredible resilience and caring they H demonstrate every day. â&#x2013; Murray T. Martin is President and CEO of Hamilton Health Sciences.

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30 Focus

New armband improves patient safety in hospitals By Ken Caskenette or years, it has been standard practice in hospitals. Patients arriving at registration are issued an armband to identify who they are. In some instances, they may receive two, three, four, and up to five bands of differing colours, each one alerting medical staff of a specific issue, from allergies to ‘do not resuscitate’ (DNR) orders to blood type. New studies show, however, that armbands – the very tool designed to improve patient safety and reduce risk of error – have the potential to do just the opposite. According to a survey by the Institute for Safe Medication Practices, coloured armbands can cause confusion. In one instance, the study found that a patient allergy went unnoticed, causing him to go into anaphylactic shock despite the fact he was wearing a colour-coded bracelet to alert clinicians to his allergy. In another case, an armband designating ‘restricted extremity’ was mistaken as ‘do not resuscitate (DNR)’. A separate U.S.-based study discovered that illegible information on armbands accounted for 24 per cent of all armband-related errors. In addition, the cutting and chafing caused by the design of some armbands puts patients at higher risk of contracting superbugs, common in today’s hospitals. Due to the rugged and wet nature of care environments, the armbands themselves can also become illegible, leaving even more room for human error. What’s more, a study in the September 2013 Journal of Patient Safety reports that between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to


The new armband is much softer and can be comfortably worn for up to 25 days. their death. Errors may include hospitalacquired infections, medication mix-ups and other mistakes. Now, hospitals have access to a new solution to patient identification issues, thanks to the development of a groundbreaking new armband that is receiving worldwide attention for its super-softness, low cost and ability to increase patient safety. The supersoft armband is water and chemical proof, and can be comfortably worn for up to 25 days without causing skin irritation, cuts, nicks or sores, or losing legibility. The easily-printable bands also remove the need to use multiple coloured armbands. Officially launched at the Ontario Hospital Association’s HealthAchieve Conference in November by Toronto-based Me-

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Hospitals have access to a new solution to patient identification issues, thanks to the development of a new armband that is receiving attention for its supersoftness, low cost and ability to increase patient safety direx Systems, the product is already being used at several Canadian hospitals with rave reviews. Among the first to use the groundbreaking armbands are Newfoundland’s Western Health, and Ontario’s Georgian Bay General Hospital, Perth and Smiths Falls District Hospital and St. Joseph’s General Hospital in Elliot Lake. St. Joseph’s General Hospital in Elliot Lake, Ontario, which serves 25,000 residents in Northern Ontario, for example, is using Medirex armbands to distinguish between only two patient populations – those at risk and those not at risk – by adding a single red border band to the white arm-


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bands to alert clinicians to at-risk patients. Clinicians then rely on information contained in the armband’s barcode or hospital information system to correctly identify the risk. “Our raison d’être for selecting Medirex was to find an armband solution that was legible and long-lasting, that could accurately and readily identify patients,” says Pierre Ozolins, St. Joseph’s Assistant Executive Director, Patient Care Services. “What is the benefit of a readable armband? Nobody really knows the value until you have a catastrophic event that could have been avoided.” According to Ryan Crocker, one of three regional managers of health information at Newfoundland’s Western Health, “The Medirex armbands are very different from anything else we looked at.” He noted that the product is so soft, he was surprised by its durability, and with cost savings associated with the armband. At Georgian Bay General Hospital in Ontario, the Medirex armbands – which they describe as having a similar feel to fabric – are being used to identify all outpatients, and have allowed the hospital to move from a four-armband system to a single armband with two colour-coded stickers for alerts, all printable on a single sheet of paper. As an added advantage, the Medirex armbands make barcode solutions affordable for those hospitals that have yet to implement bedside scanning due to the high cost of other products. Rather than creating the need for revamping an existing system, Medirex armbands include software that interfaces to existing systems, printing armbands and labels in a readable, customizable format that makes it easy to adhere to standards. Initial response to the armbands has been so positive that the company is looking to sell them to hospitals globally startH ing in early 2014. ■ Ken Caskenette is President of Medirex Systems Inc., a healthcare solutions company.


Focus 31


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CAEP Membership There is Strength in Numbers!

Membership provides exclusive benefits, and professional opportunities to help advance emergency medicine in Canada. Exclusive Member Benefits • • • • • • •

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December 2013 Edition  

Focus on Women's Health, Men's Health and Year In Review

December 2013 Edition  

Focus on Women's Health, Men's Health and Year In Review