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Smoking cessation support at the North Bay Regional Health Centre FOCUS IN THIS ISSUE

CARDIOVASCULAR CARE/ DIABETES/RESPIROLOGY:

Canada's Health Care Newspaper JULY 2013 | VOLUME 26 ISSUE 7 | www.hospitalnews.com

Developments in the prevention and treatment of vascular disease including cardiac surgery, diagnostic and interventional procedures. Advances in treatment for various respiratory disorders including asthma, allergies. Prevention, treatment and long term management of diabetes and other endocrine disorders.

Cardiac cath lab celebrates 25th anniversary

INSIDE Natural Path .......................................19 Nursing Pulse .....................................22 From the CEO's desk.......................... 24 Patient Safety ..................................... 27 Ethics ..................................................30 Careers ............................................... 31

A matter of life and death William Osler provides Brampton-area patients with timely access to services, closer to home By Cara Francis

I

t has been said that timing is everything. In Tom Holloway’s case, truer words were never spoken. On April 18, 2013 at approximately 7:00 p.m., Tom was rushed to William Osler Health System’s (Osler) Brampton Civic Hospital site by Peel Regional Paramedic Services with chest pain, numbness and shortness of breath. Once he reached the hospital, doctors confirmed that Tom was suffering from a blocked coronary artery. He immediately underwent Percutaneous Coronary Intervention (PCI), also known as a coronary angioplasty. PCI is considered the ‘gold standard’ for individuals experiencing a heart attack due to blocked arteries. These procedures are used to treat the patients by dilating the blood vessels of the heart with a balloon and stent. PCI is offered to a wide range of patients with heart disease, including elective patients with stable chest pain and urgent hospitalized patients with unstable chest pain. For patients experiencing a heart attack due to blocked arteries, timely access to PCI treatment can be a matter of life and death. Guidelines recommend these

Thomas (Tom) Holloway (front, centre) stands in the suite where his coronary angioplasty was performed, along with Dr. Raco (back left) and Peel Paramedics. patients receive the treatment within 90 minutes of presenting at an emergency department (ED). From the time paramedics arrived on scene to help Tom, to when his

health care team began PCI at the hospital, just 43 minutes had elapsed. Tom’s angioplasty was successful and he was out of the hospital just a few days later.

Be their link to accessing the right care Join our dedicated team of Care Coordinators

Be the health professional clients know they can count on to assess their situation both clearly and compassionately, plan and implement a plan of care that takes into consideration their unique needs, and be their guide through a complex health care system so they can make the decision that is right for them. RNs, MSWs, OTs, PTs, RDs and SLPs are invited to apply. For details, locations and employee videos, or to apply for a Care Coordinator or clinical care delivery role, visit ccacjobs.ca. Most Community Care Access Centres of Ontario are governed by the requirements of the French Language Services Act. We provide services in French and encourage applications from French-speaking candidates.

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Photo, George Beshiri and the Brampton Guardian

What Tom did not know at the time was that if his heart attack had occurred just three days earlier, the outcome may have been much different. Continued on page 7


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In Brief

The Canadian Alliance on Mental Illness and Mental Health supports federal mental illness recognition The Canadian Alliance on Mental Illness and Mental Health (CAMIMH) is pleased with the recent federal recognition of the need for a more robust disability management system addressing mental health. A key component of the broader announcement Minister Clement highlighted is that the federal government will emphasize prevention and rehabilitation and will include enhanced support for mental illness.

This is an issue that is very important to Canada's mental health providers and their patients. As one of Canada's leading providers of health care, the federal government has a leadership role to play in ensuring workplace mental health in Canada. CAMIMH is optimistic that the increased supports for workplace mental health in the announcement is a step in the right direction.

CAMIMH is pleased that the government has acknowledged with this announcement that mental illness represents more than half of all disability claims among employed Canadians, and as such needs to be addressed in a much more robust manner than it has in the past. CAMIMH trusts that the government is recognizing that federal employees are entitled to sick leave as well as disability leave as prescribed by their physicians or

Canada’s official robotic surgery training centre is operational London Health Sciences Centre’s (LHSC) was recently selected by Intuitive Surgical Inc. – manufacturer of the world’s most sophisticated and widely used surgical robot, the da Vinci Surgical System – as the exclusive training centre for robotic surgery in Canada. Offered through LH-

SC’s Canadian Surgical Technologies and Advanced Robotics (CSTAR) program, training has now commenced for surgeons who will travel to London from across Canada and beyond to learn the very latest surgical robotic techniques. “Earning the designation as Canada’s

Women's College Hospital unveils hospital of the future

Canadian healthcare reached a milestone recently as Women's College Hospital (WCH) (www.womenscollegehospital.ca) unveiled the Hospital of the Future, a new state-of-the-art ambulatory (outpatient) care facility that is revolutionizing the way healthcare is provided to women and diverse communities in Canada. "Our new facility represents one of the biggest Canadian advancements in ambulatory care," WCH president and CEO Marilyn Emery says. "We are developing innovative models of care that are helping to keep people out of hospital. This is the future of healthcare. We combine treatments, surgery, research and education all in one place to deliver superior -

and more efficient - care and to improve our health system as a whole." WCH is Canada's leading academic, ambulatory hospital and a world leader in the health of women. The hospital's 100-year-old legacy is built upon a number of "firsts" - the first Canadian hospital to train women physicians, use mammography and develop a simplified Pap test for detecting cervical cancer. "Today, we provide healthcare without an emergency room and perform vital complex surgeries without inpatient beds," says Emery. "And we do this with the best treatment outcomes and the highest rates of patient satisfaction. This is the goal of ambulatory healthcare. This is H the goal of WCH." ■

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sole training centre for robotic surgery is a tremendous honour for LHSC and reinforces our position as a world-class centre for surgical innovation and research,” said Bonnie Adamson, President and CEO of LHSC. Most importantly, as a result of this training, patients from coast to coast will have more access to minimally invasive procedures, which inevitably will lead to better patient outcomes.” In the first week, three surgeons trained at LHSC. “Each surgeon receives a full day of training on the da Vinci Surgical System,” says Dr. Lara Murphy, da Vinci trainer, LHSC. Surgeons are able to familiarize themselves with the equipment and practice the movement of the robotic arms and camera before practicing surgery on tissue. Surgeons will be trained to use the system for urology, gynecology, and upper and lower gastrointestinal surgery for both adult and paediatric patients. “In the future, we plan to add training programs for cardiac and ear, nose and throat surgeries.” Before the surgeons arrive at LHSC, they observe robotic surgeries in their own hospitals and complete an online training module and exam about the robot. After their training at LHSC they will return to their own hospital and begin to perform surgeries under the supervision of expert proctors. The goal is to help make this technology available to as many Canadian patients as possible by training every surgeon in CanH ada who is interested in robotic surgery. ■

mental health practitioners as it brings forward improvements to the short and long term disability benefits. As an employer, the federal government can ensure that the extended health plans it offers to its employees provide meaningful coverage for mental health treatments and supports. CAMIMH is encouraged by this announcement, and its members look forward to working with the federal govH ernment in its implementation. ■

Mount Sinai makes historic philanthropic announcement

Mount Sinai Hospital recently announced that Larry and Judy Tanenbaum have made a transformative $35 million gift in support of research at the Hospital. In recognition of the gift, the Hospital’s research institute will be re-named the Lunenfeld-Tanenbaum Research Institute. The Lunenfeld-Tanenbaum is already ranked among the top ten medical research institutes in the world and this gift will propel further growth that will transform patient care in the future. The gift by Larry and Judy Tanenbaum launches a major fundraising drive with the goal of achieving a $50 million endowment to sustain and grow the leading-edge research at the Lunenfeld-Tanenbaum Research Institute. The gift will support the research of internationally recognized investigators working towards the prevention, detection and treatment of health conditions that are aligned with Mount Sinai’s flagship clinical programs. These include cancer, diabetes, rheumatoid arthritis, maternal and infant health, neurodegenerative diseases and mental health disorders. The Lunenfeld-Tanenbaum Research Institute is home to Canada’s largest research team focused on maternal and infant health and ranks #1 in diabetes research among academic hosH pitals worldwide. ■

Bridgepoint Hospital celebrates the official opening of its state of the art facility The opening of the new Bridgepoint Hospital (www.bridgepointhealth.ca) has forever changed the healthcare landscape in Canada. The new state of the art facility is transforming the way healthcare is delivered to individuals living with complex health conditions and those in need of rehabilitation. "Everything in this hospital is deliberate and by design. It is a convergence of excellence in technology, clinical expertise, research and teaching, specifically driven to find real world solutions and help people with complex health conditions live better," said Bridgepoint President and CEO Marian Walsh "This hospital is a hub of innovation and represents the beginning of a new era in healthcare." The new hospital has 14 units provid-

ing superior patient care and rehabilitation. It has therapy gyms on every patient floor, a unique glass walled therapy pool and more living spaces and amenities for patients, including a shared dining room, lounges and a roof top terrace. The modern ambulatory care space provides extraordinary outpatient and community programming. In addition to the hospital, Bridgepoint consists of the Collaboratory for Research and Innovation that is focused on developing best practice evidence for treating patients with complex health conditions, the Family Health Team responsible for healthcare management and prevention and the Foundation dedicated to raising funds that support the world class research and cliniH cal care provided at Bridgepoint. ■ www.hospitalnews.com


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Hitting the Southlake Regional Health Centre: road to improve cancer screening rates ancer Care Ontario is driving access to cancer screening – literally – with the introduction of two new Screen for Life coaches for breast, cervical and colorectal cancer screening. On the road in the next few weeks, the new Screen for Life coaches are capable of travelling to different communities in northern Ontario and the Hamilton-area, bringing much needed services closer to home for women who face barriers to screening. Breast and colorectal screening services will be accessible to women between the ages of 50 and 74, and cervical cancer screening services will be available to women between the ages of 50 and 70. The coaches are about the size of a Greyhound bus and are outfitted with state-of-the-art digital mammography equipment, as well as trained medical staff members that are able to perform Pap tests. The coaches will also be handing out Fecal Occult Blood Test (FOBT) kits, the at-home test for colorectal cancer screening. The northern Ontario coach will travel to remote areas, replacing a previous mobile screening service that has been offering mammography in the communities since 1992. It is operated by the Northwestern Regional Cancer Program at Thunder Bay Regional Health Sciences Centre. The Hamiltonarea coach is new to the community and will serve three priority areas, focusing on women who have cultural or social barriers that prohibit them from discussing or participating in screening initiatives with their primary care providers. It is operated by the Hamilton Niagara Haldimand Brant Cancer Program at Hamilton Health Sciences. "Regular cancer screening can detect cancer at an early stage before symptoms develop, or detect changes that lead to cancer," says Michael Sherar, president and CEO for Cancer Care Ontario. "This is why we are reaching out to women in their communities to ensure H they have equal access to care." ■ This article was provided by Cancer Care Ontario.

C

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Aboriginal Culture Awareness Celebration Day By Judy Murdoch Southlake Regional Health Centre recently celebrated the culture and contributions of local First Nations people at the Aboriginal Culture Awareness Celebration at Southlake event. Staff, volunteers, patients, and members of the community learned about First Nations traditions and customs, including those surrounding birth and death, from leaders and members of the Aboriginal community. “We are so pleased to welcome members of our local First Nations people to Southlake and thank them for sharing their traditions and cultural teachings with us,” says Dr. Dave Williams, Southlake President & CEO. “By learning more about the beliefs and way-of-life of our First Nations people, I am confident that we can provide them with more meaningful and positive healthcare experiences in the future.”

“I think it is important for the non-native community to know that we are a very Spiritual people.” Organized by the Hospital’s Diversity, Inclusivity & Accessibility Committee, in partnership with the Georgina Arts Centre & Gallery, and supported by a grant from The Rotary Club of Newmarket, the Aboriginal Culture Awareness Celebration at Southlake treated guests to traditional drum teachings, spiritual practice and traditions, a smudging ceremony, healing circle discussions, serving of feast foods, stages of life teachings, and a Woodlands Canadian Artists Exhibition, which included artworks by Jay Bell Redbird, Halina Stopyra and LauraLee K. Harris. Guests had the opportunity to interact with exhibitors and engage in conversation about Aboriginal customs and traditions. Special presentations were made by Elder Duke Redbird, Ontario College of Art and Design’s New Aboriginal Advisor & Mentor; Suzanne Smoke, Aboriginal Cultural Coordinator, Biindigen Gallery – Georgina Arts Centre & Gallery, Jacob Charles,

Jacob Charles, Chippewas of Georgina Island First Nation, CEO of First Nation Cultural Tours, blesses the opening ceremony with a song Chippewas Of Georgina Island First Nation and CEO of First Nation Cultural Tours; and Ralph King Jr., Ogamawahj Medicines, from Moose Deer Point First Nation, Native Healer. According to Mary Ryan, Chair of the hospital’s Diversity, Inclusivity and Accessibility Committee, the event is the first of many to celebrate the many diverse communities and groups of people who rely on Southlake to meet their healthcare needs. “We want to raise awareness, celebrate and promote an understanding of the rich cultural diversity of our communities to create a welcoming environment for all – our staff, physicians, volunteers and the patients and families we serve,” said Mrs. Ryan. “We look forward to hosting events to celebrate other cultures in the future.” Featured in the cover article of the most recent edition of Southlake’s quarterly magazine, Beingwell, Suzanne Smoke was keen to share traditions she knew would pique the interest of guests attending the various sessions held throughout the day. Suzanne visited the Hospital’s maternal child program to talk about the role of

prayer and the various customs that are important to the Aboriginal community during various stages of life, including birth. “I think it is important for the nonnative community to know that we are a very Spiritual people,” says Suzanne, who told attendees that prayer for the Earth and the environment are an integral part of First Nations beliefs. “Everything we need to survive comes from the Earth. We come from the Earth. What happens to the Earth happens to us. We have a responsibility to look after the Earth.” In honour of the region’s rich Aboriginal heritage, Southlake’s cafeteria was renamed Aquene Café as part of the day’s celebration. The word Aquene is of Native origin and means ‘peace’. It was chosen as the preferred name from those submitted during a contest held several weeks ago to rename the hospital’s newly redesigned cafeteria. The name was submitted by Tammy Coe, a member of the Southlake H team and Metis community. ■ Judy Murdoch is a Media & Government Relations Specialist at Southlake Regional Health Centre.

JULY 2013 HOSPITAL NEWS


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Editorial

UPCOMING DEADLINES AUGUST 2013 ISSUE EDITORIAL JULY 5 ADVERTISING: DISPLAY JULY 26 | CAREER JULY 30 MONTHLY FOCUS: Emergency Services/Critical Care/ Trauma/Emergency Preparedness: Emergency and trauma delivery systems and emergency preparedness issues facing hospitals. Advances in critical care medicine.

SEPTEMBER: 2013 ISSUE EDITORIAL AUG. 2 ADVERTISING: DISPLAY AUG. 23 | CAREER AUG. 27 MONTHLY FOCUS: Patient Safety/Research/ Infection Control: Developments in patient safety practices. An overview of current research initiatives. Innovations in the prevention and treatment of drugresistant bacteria and control of infectious diseases, including HIV/AIDS and hepatitis. Advances in the measurement of patient outcomes and program metrics.

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Attacking the myths about heart attack

A recent social networking post outlines a technique for surviving a heart attack while alone that involves vigorous coughing. According to the email, an unnamed cardiologist has advised forwarding the message to others in order to save lives. Truth or hoax? Like many other ‘useful’ posts and emails in circulation on our social networks this one contains an element of truth but is basically a hoax. Although the cough procedure has been researched and tested by medical professionals, cough CPR should not be attempted alone and should only be performed under strict professional supervision. According to the American Heart Association, "the usefulness of 'cough CPR' is generally limited to monitored patients with a witnessed arrest in the hospital setting". The message advises continuing the cough CPR in between deep breathing and waiting for help to arrive. At least part of this message is true. At the first warning signs, even if you only suspect that you are having a heart attack – call 911 immediately. According to the Canadian Heart and Stroke foundation, here are the warning signs of heart attack: • Chest discomfort – it may feel like pain but is also described as uncomfortable chest pressure, squeezing, fullness or burning • Discomfort in other areas of the upper body such as neck, jaw, shoulder, arms or back • Shortness of breath • Sweating • Nausea • Light-headedness Heart attack symptoms for women appear to be a little less predictable than for men and therefore are sometimes missed – sometimes even by health care professionals.

What is the number one heart attack symptom for women prior to a heart attack? Surprisingly it’s fatigue. Unusual fatigue is a major symptom of heart attack for women as is weakness, cold sweat and dizziness. Although it was believed that women's cardiovascular risk factors and symptoms differed from those of men, it may just be that women experience and/or describe pain differently from men. If you are experiencing any or all of these symptoms, call 911 immediately. Stop all activity and sit or lie down in whatever position is most comfortable. If you take nitroglycerin, take your normal dosage. If the 911 operator advises it, chew and swallow one adult tablet of aspirin or ASA if you are not allergic or intolerant. Do not substitute other pain killers such as Tylenol or ibuprofen for aspirin. According to Women’s Health Matters, the information portal for Women’s College Hospital, women are more likely to die from heart attack than men, probably because they do not report their symptoms to their doctors as frequently as men. Cardiovascular disease, although once considered a ‘man’s killer’ is the number one killer of women in Canada and worldwide. So it is very important to become informed about the risks and ways to protect yourself from heart disease as well as to know how to recognize the warning signs. Always be cautious about what you read on the internet, even if the information seems well intentioned and well informed. In this issue we have a number of features that will put your mind at ease that your heart is being well cared for. Our cover story looks at how William Osler’s Brampton facility moved to around-theclock ST-Elevation Myocardial Infarction or ‘Code STEMI’ coverage for patients requiring life-saving coronary angioplas-

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ty. For patients this not only means rapid access to treatment but could mean the difference between life and death. We also look at how Cardiac Services BC, an agency of the Provincial Health Services Authority (PHSA), has successfully implemented the first province-wide cardiac information system in Canada to support clinical care, quality assurance and improvement, and outcome-based research. Hopefully other provinces will gain valuable information and strategies from BC’s system. We also look at innovative technologies such as London Health Sciences’ device called the HeartMate II Left Ventricular Assist Device (LVAD) which was developed with the goal of providing years of circulatory support for patients in heart failure, allowing them to leave the hospital and return to their lives as they await the availability of a donor heart. Collaboration is a key to success in many ventures and that’s why we feature a unique collaboration between Hamilton Health Sciences and Niagara Health System (NHS) that has brought cardiac catheterization services to the new St. Catharines’ site of NHS. Both facilities are committed to the vision of one regional and integrated program delivered at two sites. Cardiac Rehab has been an important part of any cardiac recovery program for some time but some facilities, such as Thunder Bay Regional Hospital recognize that prevention is better. That’s why they have expanded their programming to include high-risk clients to help them delay or, even better, avoid heart events. Their program focuses on diet and exercise and life-style changes and oneon-one coaching to help clients achieve their health and fitness goals. We hope you enjoy this issue, and as always, we welcome your comments and H feedback. ■

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iPads and action plans:

A new approach to helping patients with asthma By Patricia Favre

A

sthma is a chronic and potentially fatal disease affecting 8.3 per cent of Canadians aged 12 and over, with annual health care costs of more than $1.55 billion. Even though asthma can be well controlled in most patients, the majority of cases remain poorly controlled. Dr. Samir Gupta, a respirologist at St. Michael’s Hospital in Toronto, said he believes an innovative pilot project launched this month (July) can improve those outcomes. Dr. Gupta’s study focuses on giving more patients asthma action plans, personalized guidelines for self-management of symptoms, through a waiting room iPad application. “Previous studies have shown that action plans can significantly improve symptoms and quality of life and relieve patient dependency on the health care system,” said Dr. Gupta. “For example, a patient using an action plan can expect less emergency room visits and better attendance at school or work.” Kelly Pavelick, 47, has dealt with asthma her whole life. She has had an asthma action plan since she started seeing Dr. Gupta a few years ago and keeps it pinned up on her kitchen cupboard. “An asthma attack can make you feel like you don’t have control,” said Pavelick. “My asthma action plan gives me back a sense of control by helping me to manage and understand my symptoms.” Even though asthma plans are effective, just 11 per cent of asthma patients have one. “Unfortunately, most primary care physicians lack the time or the skills required

Dr. Samir Gupta shows research students how an iPad application can collect necessary patient information for an asthma action plan. to develop an action plan,” said Dr. Gupta. “Our project tackles both of those challenges. It puts the time piece on the patient and puts the knowledge piece into our decision support system.”

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The application requires asthma patients to complete a simple touch questionnaire on an iPad in the physician’s waiting room. It uses best evidence to determine whether a patient has acceptable asthma control or whether the patient requires any changes to medications, and produces a personalized asthma action plan.

If the study is successful, Dr. Gupta hopes to take the new application across the country – and perhaps in an even easier-to-use format. The data is then sent to the clinician’s electronic medical system. By the time the patient walks into the doctor’s office, the plan is ready. The physician can easily alter the plan if desired, save it to the patient’s chart and print for the patient. “We’re hoping that we can see a significant increase in the rate at which patients are receiving asthma action plans,” said Dr. Gupta. “We also want to see more patients learn to control their asthma – we will be measuring patient use of hospitals and emergency departments as a result of the study.” The study is being conducted at two intervention sites in Hamilton and

Photo by Yuri Markarov, St. Michael’s Hospital

Brampton, the Hamilton Family Health Team and the Wise Elephant Family Health Team, and at two control sites in Mississauga and Toronto, the West Mississauga Clinic and the Kennedy Medical Clinic. The electronic action plan application is already in use at the intervention sites. The control sites will receive the new system next year. For now, control site physicians have conventional paperbased action plan templates that they can fill out. At the end of the one-year study period, results will be compared to see if the doctors using the electronic application prescribed more action plans than the doctors employing usual care. If the study is successful, Dr. Gupta hopes to take the new application across the country – and perhaps in an even easier-to-use format. It could be made available as a free internet download for users through their smartphones. Asthma is one of the many conditions treated at the St. Michael’s Respirology Clinic. The clinic receives roughly 28,000 patient visits per year and has the largest and busiest pulmonary function lab in Toronto. The clinic also has the largest Canadian clinic subspecialties for adult cystic fibrosis, Hereditary Hemorrhagic Telangiectasia, tuberculosis, and Hantavirus PulmoH nary Syndrome. ■ Patricia Favre is Senior Communications Adviser at St. Michael’s Hospital. www.hospitalnews.com


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Timely access Ramadan observers are being helped to fast safely to services at By Dahlia Reich William Osler B Continued from page 1 On April 15, 2013, Osler moved to around-the-clock ST-Elevation Myocardial Infarction or ‘Code STEMI’ coverage for patients requiring PCI. For almost a year, Osler had been performing daytime code STEMI service direct from the field with Peel Regional Paramedic Services and from Osler EDs. As of April 15 however, Osler expanded the service to cover nights and weekends. Before that time, patients requiring afterhours code STEMI service were brought to other hospitals within the region, but approximately 30 minutes away. These 30 minutes could have had a significant impact in Tom’s situation. The longer he went without PCI, the more damage his heart would have sustained. “I’m extremely fortunate that this service became available when it did,” said Tom Holloway. “It’s important that services like these are offered close to home and there for you when you need them most. I can’t say enough good things about the health care team that treated me, and about the follow-up care I am currently receiving at Brampton Civic Hospital.”

eginning July 9, thousands of Muslims will begin a month of a daily fasting from dawn until sunset in observance of Ramadan. This is an important period of religious devotion and spiritual reflection but for Muslims with diabetes, it can pose serious health risks if planning is not done well ahead. “It’s very common for those with diabetes who observe Ramadan to run into trouble with lows and highs in blood sugar levels,” explains Dr. Mervat Bakeer with the Primary Care Diabetes Support Program (PCDSP) of St. Joseph’s Health Care London. “It’s critical they plan for Ramadan by learning how to adjust their medi-

cations for fasting, about insulin use and careful monitoring when fasting, when to break the fast, and diet during Ramadan.” For the first time, St. Joseph’s is providing a service to help those with diabetes stay healthy during Ramadan. Individuals can receive the guidance and support they need through the PCDSP. No referral is necessary. “There is a great need to provide this service,” says Dr. Bakeer, a family physician who specializes in diabetes. “Many people are fasting without any planning or guidance and are taking risks. They avoid testing their blood sugars because they don’t want to break the fast and run into problems with hyperglycemia or hypoglycemia.” An estimated 3,000 Muslims in London are living with diabetes. Dr. Bakeer

says that research looking at the epidemiology of diabetes and Ramadan indicates that more than 40 per cent of Muslims with type 1 diabetes and nearly 80 per cent with type 2 diabetes fast during Ramadan, and most don’t change how they manage their diabetes while fasting. Dr. Bakeer urges people to see their family doctor before Ramadan or to call the PCDSP to make an appointment. At the PCDSP, located at St. Joseph’s Family Medical and Dental Centre on Platt’s Lane, individuals will be assessed and a plan developed to see them through Ramadan, including weekly visits or moniH toring by phone or email. ■ Dahlia Reich is in Communication & Public Affairs at St. Joseph's Health Care, London.

"It takes a finely synchronized and cohesive group effort to produce the outcomes that we have achieved at Osler in just a short period of time.” PCI is an important service for Osler given the growing incidence of heart disease within the region, as well as the community’s higher than average prevalence for chronic diseases such as diabetes, which is linked to heart disease. About 36 per cent of residents have one chronic condition and 14 per cent have multiple chronic conditions. The rate of diabetes is the third highest in the province and expected to continue to rise. “Bringing around-the-clock access to STEMI has been a tremendous team effort involving colleagues from across the organization – both in clinical and administrative functions,” said Dr. Dominic Raco, Corporate Chief of Cardiology and Medical Director Cardiovascular Health System. “We are very fortunate for the support we have had for the program at all levels of the hospital. It takes a finely synchronized and cohesive group effort to produce the outcomes that we have achieved at Osler in just a short period of time.” For more information about Osler programs and services, go to www.williamoslerhs.ca. William Osler Health System (Osler) is a hospital system ‘Accredited with Exemplary Standing’ from Accreditation Canada serving 1.3 million residents of Brampton, Etobicoke, and surrounding communities of the Central West Local Health Integration Network. Osler delivers more babies than any other hospital in the province, and its emergency departH ments are among the busiest in Ontario. ■ Cara Francis is Manager, Public Relations and Digital Communications at William Osler Health System. www.hospitalnews.com

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Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

The search for an early biomarker to fight atherosclerosis By Marie-Josée Nantel

he Journal of the American Heart Association recently published the conclusive results from a study directed by Dr. Éric Thorin of the Montreal Heart Institute (MHI), which suggests for the first time that a blood protein contributes to the early development of atherosclerosis. Dr. Thorin, his team and his collaborators discovered that the blood levels of angiopoietin-like protein 2 (angptl2) are six times higher in subjects with coronary heart disease than in healthy subjects of the same age. Their basic research study also revealed that angptl2, which is undetectable in young mice, increases with age in healthy subjects and increases prematurely in subjects who have high cholesterol and pre-atherosclerotic lesions. Entitled “Angiopoietin-like 2 promotes atherogenesis in mice,” this study was conducted using an animal model consisting of three to twelve-month-old mice. These results represent a major advance in the prevention and treatment of atherosclerosis. “Although much work remains to be done to broaden our knowledge of this protein's mechanisms of action, angiopoietin-like protein 2 may represent an early biomarker not only to prevent vascular damage but also to predict atherosclerotic disease,” explained Dr. Thorin. Preventing cardiovascular disease is an important goal both to increase healthy life expectancy and decrease pressure on our health care system. For 15 years, Dr. Thorin, a researcher at the MHI Research Centre and a full professor at Université de Montréal, has been interested in the evolution of artery function during the aging process and in the underlying mechanisms of atherosclerosis. More specifically over the past five years, he has looked at the role of this particular protein. His work has led to a better understanding of the processes induced by angptl2 and that accelerate the progression of the disease. First of all, angptl2 triggers very intense vascular inflammation and recruits leuko-

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cytes to adhere to the vascular endothelium, which is a single layer of cells lining the lumen of vessels and whose integrity is essential to good vascular function and blood flow. The adhesion of leukocytes, or the circulating cells of the immune system, is considered a trigger for atherosclerosis, especially when an abundance of these cells are rolled and tethered onto artery walls to eventually cause atheromatous plaque. The second important component of this study is the demonstration that a onemonth infusion of this protein in mice considerably increased circulating cholesterol levels. This discovery was unexpected, as angptl2 was not known to have an impact on cholesterol metabolism. This finding is all the more important because a high level of blood cholesterol promotes the development of atherosclerosis. The study showed that the levels of this protein increased in the blood of patients with cardiovascular disease even though all of these patients were treated with a statin, which normalized their high baseline cholesterol levels. Statins are not a blanket solution, as they reduce cardiovascular events in only around 35 per cent of patients. High levels of angptl2 may therefore be a marker for at-risk subjects, which only future research will show. Previous studies indicated that angptl2 blood levels increase in subjects with certain autoimmune diseases as well as diabetes, obesity and cancer, or diseases that damage the small blood vessels and that are associated with chronic inflammation. According to Dr. Anil Nigam, a cardiologist and specialist in cardiovascular disease prevention at the MHI and co-author of the study, “Prevention is the ideal solution to delay the onset of atherosclerosis, and an early blood marker such as angptl2 – if future clinical studies confirm this finding – will serve as an important tool to identify at-risk subjects who do not present with H any symptoms of atherosclerotic disease.” ■ Marie-Josée Nantel is a Communications Officer at the Montreal Heart Institute.

Bluewater Health Physiotherapist Jennifer Verslype uses neuromuscular electrical stimulation to assist the wrist movement of patient Al Degroot.

Bluewater Health: Supporting rehabilitative stroke care and education By Meaghan Lawrence-Kreeft ehabilitative therapy following a stroke can produce dramatic results in patients’ functional abilities and is an important part of stroke recovery. At Bluewater Health, an interprofessional team provides rehabilitative stroke care, including physiotherapists, occupational therapists, recreational therapists and speech pathologists.The rehabilitative goal is to improve function to enable the stroke survivor to become as independent as possible. This includes increasing movement, strength, flexibility and endurance, and often re-learning basic skills such as talking, eating, dressing and walking. On June 8 and 16, Bluewater Health rehabilitative therapists took part in education events advancing their knowledge and skills related to best practice to enhance stroke patient care.

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Linda Dykes, Manager, Sarnia-Lambton District Stroke Centre, says that by supporting these types of education activities Bluewater Health is building capacity and enhancing expertise in stroke care. “By investing in our people, we’re creating a highly-skilled team of professionals that will support better recovery for patients who have experienced a stroke.” The education opportunities also coincided with National Stroke Month. Stroke is the third leading cause of death among Canadians. Bluewater Health was designated as a District Stroke Centre in JULY 2002 and

a Secondary Stroke Prevention Clinic in August 2005, as part of the Ministry of Health and Long-Term Care’s Ontario Stroke Strategy. Research shows that better diagnosis, treatment and education can dramatically reduce the number of strokes suffered by Canadians. In any stroke experience, taking immediate action is key – stroke is a medical emergency. If you experience any of the signs and symptoms of stroke, call 911 immediately. “Calling 911 is the best way to ensure you receive the care you need as quickly as possible,” says Dykes. “Time is critical. Patients who arrive at a designated stroke centre within 3 ½ hours of symptom onset may be eligible for tPA, a clot-busting drug. Calling 911 ensures you are transported to the closest stroke centre wherever you are in Ontario. In Lambton County, Bluewater Health in Sarnia is the designated stroke centre for care.” A stroke is caused by a sudden loss of function due to an interruption of blood flow to the brain. This can result from a blockage in a blood vessel or the rupture of a vessel wall. A TIA is a short-term ‘ministroke’ or ‘warning stroke’ that produces stroke symptoms. A TIA is a very serious warning sign of an increased risk of stroke. It is vital to recognize the signs and symptoms of stroke and to respond immediately. These include: • Weakness – sudden loss of strength or sudden numbness in the face, arm or leg, even if temporary. • Trouble speaking – sudden difficulty speaking or understanding or sudden confusion, even if temporary. • Vision problems – sudden trouble with vision, even if temporary. • Headache – sudden severe and unusual headache. • Dizziness – sudden loss of balance, esH pecially with any of the above signs. ■ Meaghan Lawrence-Kreeft is a Communications Coordinator at Bluewater Health in Sarnia Ontario. www.hospitalnews.com


Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

9

BC implements first province-wide cardiac information system in Canada na General Hospital, and Royal Columbian Hospital (New Westminster). Royal Columbian Hospital was the last site to go live in April 2013 and marked a milestone for the HEARTis team as all five cardiac centres in BC now have access to province-wide patient information at point of care for catheterization/percutaneous coronary intervention, cardiac surgery, postsurgery, and discharge—which ultimately improves patient care in BC.

By Lubna Ekramoddoullah Cardiac Services BC, an agency of the Provincial Health Services Authority (PHSA), has successfully implemented the first province-wide cardiac information system in Canada to support clinical care, quality assurance and improvement, and outcome-based research. Replacing an obsolete registry, the Heart Information System (HEARTis) introduced a single point-of-entry solution on a web-based platform. It tracks a patient journey for all current and future cardiac procedures—no matter where they are treated in BC—from registry on the waitlist to procedure completion and follow up.

About Cardiac Services BC

Cardiac Services BC is dedicated to ensuring all British Columbians have access to the best possible services for cardiac care. CSBC is responsible for the planning, coordination, monitoring, funding, and evaluation of cardiovascular disease-related treatment services as well as secondary prevention. CSBC provides a service coordination role for British Columbians by assessing service needs across all regions of the province and determining the most appropriate and cost effective means of meeting those needs.

HEARTis improves the speed and access for clinicians to critical health-related information, eliminating the need to manually track down and transfer patient records. HEARTis replaced the BC Cardiac Registry, a 20-year-old registry that was technologically outdated and used software that was no longer supported by the vendor. There were delays entering and accessing patient information due to manual data entry. In order to mitigate the risk of not having necessary cardiac data due to the outdated technology and to realize the significant gains from a comprehensive cardiac information system, Cardiac Services BC initiated a project team to develop a new system. The team included multiple vendors and nearly 100 cardiologists, cardiovascular surgeons, nurses, senior administrators, and staff from privacy, risk, and IT departments from all five regional health authorities in BC. The project scope included: design of the clinical modules in partnership with a small vendor based on best practices and national standards and in collaboration with cardiac clinicians; extensive data migration from the old registry; and the requirement to interface with 11 hospital IT systems. HEARTis improves the speed and access for clinicians to critical health-related information, eliminating the need to manually track down and transfer patient records. HEARTis also standardizes processes and reporting, providing enhanced research and quality improvement capabilities. System components include: • increased efficiencies in the collection and management of cardiac services data; • expanded functionality; • improved research and reporting; • improved information technology stability; • standardization of processes across all sites; and • capture of patient journey in a single system. Due to widespread end-user training and support, the implementation was a success. Positive results from HEARTis include time savings and improved availwww.hospitalnews.com

About PHSA

ability of and access to information. For example, the time to enter a cardiac surgery report into the system went from 20-30 minutes in the old registry to 1020 minutes in HEARTis. That is an approximate time savings per surgery case of 10 minutes. With an average number of cases per month at 59, this is a time savings of 590 minutes per month or 1.3 FTE days per month. Similarly, the time

to send out clinical reports to copied physicians went from seven to two days (57 per cent improvement), and the time for finalized clinical reports to be entered went from seven days to one (86 per cent improvement). HEARTis has been implemented at five provincial sites: Royal Jubilee Hospital (Victoria), St. Paul’s Hospital (Vancouver), Vancouver General Hospital, Kelow-

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JULY 2013 HOSPITAL NEWS


10 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

LHSC introduces heart failure support device By Kathy Leblanc ondon Health Sciences Centre (LHSC) is home to the country’s longest running heart transplant program, with over 600 transplants performed since it was established in 1981. Until now, many patients with advanced heart failure requiring a transplant have had to remain in hospital while awaiting a donor organ. Hooked up to intravenous pumps providing life-saving medication, these patients were limited in what they could do, drastically impacting their quality of life. “Because there aren’t enough donor hearts to meet the need of these advanced heart failure patients, people waiting for their heart transplant have a very real risk of organ failure and death,” said Dr. Dave Nagpal, LHSC cardiac surgeon. “To temporize the situation, we sometimes need to admit people to hospital for intravenous treatment and often, these patients would have had to wait in hospital for an indeterminate length of time until a donor organ was available.” 33-year-old Suzana De Sousa is the one of those patients. De Sousa was in hospital awaiting a life-saving heart transplant, needed as a result of congestive heart failure, for over 73 days. Recently, she was able to return home to Kitchener, Ontario thanks to a new heart support device available to eligible cardiac patients at LHSC.

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The device is called the HeartMate II Left Ventricular Assist Device (LVAD) developed by Thoratec Corporation. An internally implantable device, the LVAD was developed with the goal of providing years of circulatory support for patients in heart failure, allowing them to leave hospital and return to their lives as they await the availability of a donor heart. De Sousa is the second patient at LHSC to receive the device. This is an important development for patients, not only because of the quality of life they are able to regain, but also because the LVAD improves the circulation, it results in preserved organ function and a lower risk of death while waiting for their donor heart. Better blood circulation makes participating in rehabilitation and increasing nutrition possible, making these patients stronger and better transplant candidates, ready for the demands of a heart transplant and recovery. LHSC will also soon have a second device available to patients called the HeartWare Ventricular Assist System which is a smaller LVAD that may be better suited for some applications. “We are pleased with the result we have seen in Ms. De Sousa. She was able to go home and spend time with her family and friends rather than sitting in a hospital bed while we wait for a suit-

Suzana De Sousa was able to return home to Kitchener while awaiting a heart transplant thanks to a new heart support device. able donor heart to become available,” continues Dr. Nagpal. “I am so thankful that we have this technology to help me go home and live my life,” says De Sousa. “My family and friends have been wonderful visiting me while I have been in hospital, but nothing beats sleeping in your own bed and being

in familiar surroundings. I am happy to be one of the first people at LHSC to receive this device, and feel like I am part of the team helping to learn and advance patient H care.” ■ Kathy Leblanc is a Communications Consultant at London Health Sciences Centre.

Nurse champions promote diabetes health at Sunnybrook By Sybil Edmonds

t Sunnybrook Health Sciences Centre, education and support play a key role in helping patients successfully manage their diabetes, whether they are newly di-

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RNs:

agnosed or have been living with diabetes for years. “There were 13,000 orders for diabetes drugs for more than four thousand inpatients at Sunnybrook during 2012, which tells us there is plenty of demand for diabetes support among our patients,” says

Julie Paterson, Diabetes Nurse Educator at Sunnybrook. Sunnybrook has been working to meet that demand by implementing the Diabetes Nurse Champions program. The Champions have been working to improve diabetes knowledge, along with the qual-

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ity of care and education provided for diabetic patients throughout the Community and Brain Sciences Programs. Nurses from a variety of areas, including the hemodialysis, general medicine, intensive care and in-patient mental health units, meet on a bi-monthly basis to ensure that inpatients are receiving an appropriate amount of education and support. A further service available to patients is the Sunnybrook Diabetes Education Program (SUNDEC), which offers classes and individual counseling by registered dietitians and diabetes nurse educators. “The SUNDEC team helps diabetic patients to make healthy food choices, incorporate exercise into their daily routine, understand the role of medication, and set realistic and achievable goals,” says Paterson. To maximize the number of patients that can benefit from this service, SUNDEC accepts self-referrals from patients. The office can be reached by calling (416) 480-4805. An aging population, combined with rising obesity rates and sedentary lifestyles, is putting an increasing number of Canadians at risk for diabetes. In Ontario, the number of people living with diabetes is expected to rise to 11.9 per cent of the province’s population, or about 1.9 million people, by 2020. “Getting patients with diabetes the support and education they need now is so important, because it can make such a difference to their health further down the H road,” says Paterson. ■ Sybil Edmonds is a Communications Advisor at Sunnybrook Health Sciences Centre www.hospitalnews.com


Focus 11

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

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JULY 2013 HOSPITAL NEWS


12 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

Life-saving Toronto heart attack collaborative

Celebrating 5-year anniversary By Lauren Pelley

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evin Mundier still remembers the day five years ago when he could have lost his life. In the summer of 2008, at the age of 37, he felt the crippling chest pain of a heart attack – a pain he says was worse than breaking a bone. Kevin was having a type of heart attack known as a STEMI, or ST Segment Elevation Myocardial Infarction. This severe type of heart attack happens when an artery supplying blood to the heart becomes blocked by a blood clot, and it can potentially lead to death. But that wasn’t the case for Kevin. He was one of the first people to benefit from the Toronto Heart Attack Collaborative (THAC), an innovative alliance between St. Joseph’s Health Centre and St. Michael’s Hospital in the downtown core.

What seemed like luck for Kevin back in 2008 is now routine at St. Joe’s.

“I went straight (to St. Michael’s) and they cleared the blockage,” Kevin recalls. Even though Kevin’s heart attack happened within St. Joe’s catchment area, the joint program – which is a partnership between hospitals in the Toronto Central Local Health Integration Network, Toronto EMS and the Ontario Ministry of Health and Long-Term Care – meant that he was rushed directly to St. Michael’s for their

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HOSPITAL NEWS JULY 2013

specialized STEMI treatment. It’s a procedure that isn’t offered at St. Joe’s. “From a patient point of view, they now get the best and most appropriate treatment much more rapidly than they would in the past,” says Sandy Foster, Clinical Care Leader for St. Joe’s Emergency Department. “Prior to the launch of the THAC program, patients would have to be diagnosed and treated with medications at St. Joe's, then sent to St. Mike's for the procedure,” said Erone Newman, director of the Heart and Vascular Program at St. Michael's. “This wasn't ideal for STEMI care as it could result in life-threatening delays.” “(The procedure) has to be done promptly,” adds Julie Ann Ninnis, Patient Care Manager for the Intensive Care Unit and Coronary Care Unit at St. Joe’s. “The slogan that goes with it is ‘time is muscle’ – the heart being a muscle, and the more time that the blood flow to the heart is impaired, the more time for damage.” There’s a 90-minute window between diagnosis and the procedure where clinicians have the chance to minimize damage, she adds. To reduce this lag time, the Toronto Heart Attack Collaborative includes training for upper level paramedics in testing for STEMI heart attacks, which means the diagnosis can happen before a patient is taken to a hospital. Foster says it’s a two-pronged approach that includes both paramedics and St. Joe’s Emergency Department staff. Both groups can activate the process to send a patient directly to St. Michael’s for the treatment. “The paramedics that had dealt with me had just finished their STEMI course,” recalls Kevin. “I had unbelievable luck that day.” What seemed like luck for Kevin back in 2008 is now routine at St. Joe’s. Ninnis says around 400 patients have benefitted

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STEMI heart attack survivor Kevin Mundier (left) and St. Joe’s registered nurse Dalita Ogorkis (right). from the program to date, which includes the STEMI procedure at St. Michael’s coupled with follow-up care at the Health Centre’s Coronary Care Unit. “The collaboration between the two hospitals was the first 24-7 STEMI program in Toronto, and really served as a model for other hospitals across the city,” says Dr. Neil Fam, an interventional car-

Photo, Lauren Pelley

diologist who leads the project between St. Joseph’s and St. Michael’s. “It's been a great partnership, and we continue to tweak the system to provide the best care for STEMI patients". The struggle now, says Ninnis, is helping patients realize that they might need to make some serious life changes to stay healthy. “Sometimes (patients) just can’t believe it’s happened,” she explains. “You have a bit of pain, you call an ambulance, and they whisk you over to St. Michael’s.” The whole experience is over within a few hours, she adds, but that doesn’t mean the heart attack was any less severe. In Kevin’s case, he took his care team’s advice to heart after his STEMI five years ago – including that of Dalita Ogorkis, a St. Joe’s registered nurse. “I’m sure I was nagging you about smoking,” Dalita said with a laugh during Kevin’s recent visit to the Health Centre. Kevin says that since then, he’s quit smoking. “I try to exercise more, and I've tried to change my diet,” he adds. The 42-year-old also left his sedentary job as a tow truck driver and now works at a paving company – where he often walks two to five kilometers every day – and decided to learn CPR. Looking back, Kevin credits the THAC initiative with saving his life. “I’ve got that program to thank,” he says. “Or I probably wouldn't be sitting H here talking to you today.” ■ Lauren Pelley is a Junior Associate at St. Joseph's Health Centre Toronto.

www.hospitalnews.com


CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

Focus 13

Team approach to patients Offered at the new Centre for Complex Diabetes Care By Danielle Milley and Krista Luxton ollowing two strokes caused by diabetes and high blood pressure, Guillermo Rodas learned about the new Centre for Complex Diabetes Care (CCDC) at The Scarborough Hospital (TSH) – a specialized ‘one-stop shop’ for patients living with the disease. Since his first appointment, Guillermo has been delighted with the interprofessional care provided by the team. “When you have a chronic disease, having support to deal with not only medical, but emotional, social and economic issues is vital to minimize the tension and uncertainty that exists,” he explains. “For the first time, I felt I was being heard by a team of experts in the field of diabetes, and I believe they spent the necessary time with me for a proper medical examination to get an accurate diagnosis for future treatment.”

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A centre like this is a place where all of a patient’s care, including treatment, education and rehabilitation, will be coordinated.”

There are currently 1.2 million Ontarians living with diabetes, and with Scarborough’s diverse population, it is home to many residents who are at a greater risk for the disease, including those of Asian, South Asian and African descent. The CCDC is a regional care delivery program established to assess and support patients with diabetes who have complex needs, such as stabilization and management of blood sugar, eye monitoring, counselling and mental health supports, insulin administration and monitoring, nutritional counselling and diet planning, monitoring and management of related cardiovascular health needs, and foot and wound care, and require intensive short-term case management. It also provides a single point of access to a specialized interprofessional team that includes nurse practitioners, registered nurses, social workers, pharmacists and registered dietitians. The Central East CCDC was established at the Central East Community Care Access Centre with three care delivery sites located at Lakeridge Health, Whitby; Peterborough Regional Health Centre; and The Scarborough Hospital, General campus. Guillermo was so impressed with the www.hospitalnews.com

CCDC that he recommended the program to his wife, and after her first interview, Mrs. Rodas was pleasantly surprised to see how well the team approach worked. “We’re really so happy,” says Guillermo. “It’s the best unit we’ve found for people living with a chronic disease.” Dr. Paul Tam, Medical Director of Nephrology and Chronic Disease Management Lead at TSH, has been working with diabetes patients for more than 30 years. “If this kind of team approach had existed back when I started, it would have been heaven,” he said. “A centre like this is a place where all of a patient’s care, including treatment, education and rehabilitation, will be coordinated.” Services provided by the CCDC, include: • Support for patients including assessment, education, treatment, and transition/discharge, which utilize an intensive case management process and frequent follow-ups. • Collaboration among the patient, care team and primary care provider to develop an individualized plan that addresses the patient’s unique needs. • Support in navigating the health system as identified in the individualized care plan. • Support for providers who are involved in patient care such as specialties, primary care providers and the CCAC. • Regular communication with all providers regarding patient care plans. • Transition/discharge support as the patient moves back to his or her primary care provider or Diabetes Education Program. Garth Clarke has been receiving care for his diabetes at TSH since 2010. He was referred to the CCDC in September, and because of its team approach has gone from managing his disease on “autopilot” to taking charge of his health. “It’s great because they fashion everything to your unique needs,” he says. “I’m feeling much better and things are looking better.” The addition of the CCDC at the General campus allows TSH to better treat its diverse community that historically has presented with a high incidence of diabetes. “As a leader in chronic disease management, The Scarborough Hospital is so pleased to add the Centre for Complex Diabetes Care to our range of specialized services,” says Ethel Doyle, Director, Chronic Disease Management at TSH. “We are confident that this centre will result in fewer complications associated with diabetes, including reducing or delaying the need for dialysis, which will help us achieve our mission of providing an outstanding care experience that meets the unique needs of each and evH ery patient.” ■ Danielle Milley and Krista Luxton are both Communications Officers at The Scarborough Hospital.

Margaret Heldsinger (right), another patient who has seen success in managing her complex diabetes with the CCDC team, has lost 30 lbs and feels that the team approach made a huge difference in helping her reach her goals.

JULY 2013 HOSPITAL NEWS


14 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

Diabetes patient Karly Maloney (middle) reviews a patient questionnaire with RN Shay Cannon (left) and Dr. Karolyn Hardy-Brown, Pediatrician (right) at PRHC’s Diabetes Transition Clinic.

Positive transition for young adults is the sweet spot for PRHC’s diabetes transition clinic By Amanda Roffey or 21 year old Karly Maloney, managing her diabetes is a way of life. Diagnosed with Type 1 Diabetes in grade 3, Karly has been a patient at the Peterborough Regional Health Centre’s (PRHC) Paediatrics Diabetes program for more than twelve years and has recently moved to the Health Centre’s Young Adult Diabetes Program known as the Diabetes Transition Clinic. PRHC’s Diabetes Transition clinic is a planned approach to the movement of adolescents and young adults aged 17+ with diabetes from a paediatric diabetes environment to an adult-oriented diabetes clinic.

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“According to Diabetes Services at SickKids Hospital in Toronto: five to 10 per cent of all people with diabetes are less than 20 years old – most having Type 1 diabetes,” says Dr. Karolyn Hardy-Brown, Pediatrician at PRHC’s Paediatric Outpatient Clinic and Paediatrics Diabetes Program. “When it’s time to transition young adults from the pediatric diabetes program to the adult diabetes program that average dropout rate is between 10 to 60 per cent. These statistics are startling when you consider the long-term health risks associated with diabetes.” Since opening the Diabetes Transition clinic in April 2012, PRHC has helped ease the anxiety associated with changing from one clinical environment to another for more than 20 young adults. The Health Centre’s Paediatric Diabetes team consists of a pediatrician, registered nurse and social worker who work in partnership with the Adult Diabetes healthcare team which includes an endocrinologist, registered nurse and dietitian ensuring a smooth transition in care. “Collectively our two teams are able to transition our younger patients to the adult diabetes environment by preparing them for the changes and ensuring they understand the impacts that diabetes has on their everyday life as they move into adulthood,” added Dr. Hardy-Brown. For patients like Karly, the Transition Clinic is a huge benefit in ensuring she stays on track. “As a child you don’t really understand everything associated with Diabetes and the long-term health concerns because my parents looked after all that stuff. But as you grow older you

become more aware and begin to realize the impact of not looking after yourself. The realization that Diabetes is a chronic health condition that you need to control can be overwhelming as a young adult, but PRHC’s Transition clinic has helped me manage my condition and have given me the tools and resources for me to take control.”

“PRHC’s Diabetes Transition clinic has taught me to take control and ownership of my diabetes."

The clinic’s goal is to prepare young adults to leave the pediatric diabetes clinic by 18 years of age with the skills and knowledge needed to advocate for themselves, maintain their health promotion and self-manage their diabetes while utilizing the adult diabetes health services. “The thought of moving from a small clinical environment where the healthcare team develops a long-lasting relationship with the patient and parents to a large (1000+) environment where patients don’t really yet know their healthcare team and are expected to manage their chronic disease can be frightening when you’re a young adult,” said Dr. Hardy-Brown. “The patient response to the clinic has been

overwhelming since opening in April. Our patients appreciate the extra time we’re spending with them on education and making introductions to the adult diabetes healthcare team.” By investing up front and taking the time to help patients make the move from a paediatric to adult environment, PRHC’s Diabetes Transition clinic is having a lasting positive impact on the overall hospital by: • Decreasing emergency room visits and hospital admissions, • Decreasing long-term health conditions by ensuring patients’ diabetes are being managed and controlled, • Ensuring higher utilization of adult diabetes services and building patient and family relationships with members of the Adult Diabetes Healthcare team, • Increasing patients' confidence in their ability to self-manage and care for themselves and • Reducing the dropout rate associated with the change from one healthcare environment to another. “I’m no longer on the side lines,” said Maloney. “PRHC’s Diabetes Transition clinic has taught me to take control and ownership of my diabetes. The healthcare team is always positive and supportive. I never feel overwhelmed by the need to take responsibility and ownership over my chronic condition due to their support and guidance. The team has allowed me to set my own pace and have eased the transition H perfectly.” ■ Amanda Roffey is Communications Advisor at Peterborough Regional Health Centre. www.hospitalnews.com


Focus 15

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

New cardiology manager, new approaches to patient care By Graham Strong

n terms of admissions, discharges, and transfers, Cardiology is one of the busiest inpatient programs at the Thunder Bay Regional Health Sciences Centre. Patients spend as little as a few hours in the 6-bed angioplasty short stay unit, or as long as a week in the 36-bed inpatient unit after a major heart attack or while waiting to be transferred to another centre for cardiovascular surgery. That’s why Wayne Taylor, the Manager of Cardiology since last April, has implemented a number of multidisciplinary and teamwork approaches to help support staff in this high-stress environment – and ultimately improve patient care. “This is a very active unit,â€? Taylor said. “We’re sending patients up to the Cath Lab, to diagnostic imaging, we’re flying them out for cardiovascular surgery, we’re admitting and discharging patients from the region‌ There is a complex workflow involved, and we want to ensure our staff is properly supported to provide the highest level of patient care.â€? Taylor has continued the development of a multidisciplinary approach to cardiac recovery to improve patient care and reduce the number of re-admissions. The team has dedicated specialists like social

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workers, physical and occupational therapists, dietitians, a pharmacist, nurse practitioner, and discharge planners who assist the unit nurses and cardiologists with patient care. This team approach includes an important collaborative element that encourages feedback from all team members to constantly improve care. On average, Taylor’s unit cares for over 30 patients receiving procedures in the Cardiac Cath Lab. Many patients recover in the special 6-bed short-stay area dedicated to angioplasty patients. “With this recovery area, we provide the platinum standard of care for our angioplasty patients,� Taylor said. Within the inpatient cardiology unit, Taylor oversaw a four-month trial sponsored by the Ministry of Health and LongTerm Care’s Quality Patient Care Fund called the Healthy Work Environment Initiative. This project provided real-time learning for nurses to help them improve teamwork, meet Health Sciences Centre benchmarks for policies like hand hygiene, and improve critical thinking while working in the busy environment. “The result of this initiative is that we now have a professional practice model of care on the unit that seems to be working very well,� Taylor said. Another area that Taylor has focused on is improving the patient air trans-

Wayne Taylor is Manager of Cardiology at Thunder Bay Regional Health Sciences Centre. He has improved patient care in several ways since he joined the team last April, including promoting teambuilding within the cardiac unit and angioplasty recovery area, and ensuring patients get the appropriate level of care during air transfers. fer process for patients going outside of Thunder Bay for cardiovascular surgery or other services. Previously, a nurse would accompany the patient on the air ambulance in most cases. However in many instances, ORNGE’s own Paramedics are quite capable to oversee the transfer themselves. “We’re triaging our patients for long-

distance transfer to ensure they are getting the appropriate level of care based on medical criteria,� Taylor said. Now nurses accompany patients only in certain circumstances such as for cardiac monitoring H or to oversee certain drug infusions. ■Graham Strong is a Freelance Writer working with Thunder Bay Regional Health Sciences Centre.

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JULY 2013 HOSPITAL NEWS


16 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

Innovations at reducing the diabetic foot burden in Canada By Douglas Queen and Greg Archibald iabetes affects more than 2.7 million Canadians who live with this disease. A significant growth in the numbers of Canadians diagnosed with diabetes is predicted over the next ten years more than 3.5 million Canadians will be living with diabetes. For the Aboriginal population, the statistics are even more concerning with diabetics rates three to five times higher than that of the general population. Diabetes is the fastest-growing medical condition in the country. About 405,000 Canadians or 15 per cent of those with diabetes will develop a foot ulcer. Individuals with Diabetes are 23 times more likely to be hospitalized than someone without diabetes. Every year thousands of Canadians with diabetes lose limbs needlessly to amputation because of diabetes foot ulcers. Foot ulcers and other such diabetes complications are taking a growing, needless toll in lost limbs and lives. Diabetes foot ulcers have a considerable amount of negative impact on patients’ psychological, social and physical well-being. Not only are they susceptible to chronic wounds, infections and delayed healing, some will face the depressing consequences of losing their limbs through amputation. It is arguable that 85 per cent of these cases are preventable. Diabetic Foot Complications cost the Canadian health care system more than 150 million dollars each year. With each new case of diabetes, the impact on the health care system includes increases in emergency visits, complication rates, ulcerations, infections, and amputations, dependence upon the help of others, as well as an inability to work. Leading the charge in wound treatment and prevention across Canada, is the Canadian Association of Wound Care. Over the last 19 years of the association’s existence it has delivered several diabetic foot ulcer focused initiatives. The most recent of which were the “Diabetes Health Feet & You” and PEP Talk Programmes that is a peer led educational program on the prevention of foot ulcer. Recent externally focused partnerships with the Public Health Agency of Canada and the Canadian Diabetes Association

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have seen CAWC become a focus organisation for Diabetic Foot ulcer self management materials around the prevention and management of Diabetic Foot complications. These factors present an opportunity for CAWC for a leadership profile and to take the lead on a branded, focused approach to prevention and management of diabetic foot complications that supports both clinicians and patients in the prevention and management of Diabetic Foot complications. CAWC is leading a multi-partner initiative called Diabetic Foot Canada with several government bodies and not for profit organizations like the Public Health Agency of Canada, Canadian Diabetes Association, Canadian Home Care Association, Canadian Federation of Podiatric Medicine, Registered Association of Ontario and Ontario Hospital Association. Diabetic Foot Canada is designed to be the national 'go to' program that provides on-line information and education for Clinician and patients to support effective self-monitoring, early detection, treatment and prevention of costly and potentially life-threatening diabetes foot wounds among Canadians with diabetes.

Diabetic Foot Canada will comprise the following components:

1) Online only Diabetic Foot Canada journal 2) Diabetic Foot Canada – Stakeholder Community (VPN Social Portal) 3) A series of workshops and master classes focused on Diabetic Foot disease. 4) Peer led educational program on Prevention and management of Foot ulcers. As the initiative grows and partnerships are confirmed then other elements of research and policy will be added. The key success of this initiative will lie in multiple partners to ensure a multidisciplinary perspective and a strong patient voice. The initiative will involve, and will utilize the latest technology, evidence and national teams of interprofessional experts to provide education, disseminate best evidence and educational tools and raise awareness of the importance of preventing

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diabetic foot complications and amputations. This division is aimed at improving the lives of persons with diabetes, improving quality outcomes and reducing health H care cost. ■ Dr. Greg Archibald is a family physician and Head of the Department of Family Medicine at Dalhousie University. His area of focused practice is Wound Care

and Minor Office Surgical Procedures. He is the current President of the Canadian Association of Wound Care. Douglas Queen is the strategic Director for the Canadian Association of Wound care as well as the Business Director Welsh Wound Innovation Centre and also acts as the Editor for the International Wound Journal.

The pathway to better asthma care

By Sandra Athron

or the more than 1.7 million Ontarians living with asthma, a trip to the hospital emergency department (ED) is an ever-present possibility. Every year in Ontario, around 50,000 ED visits are due to asthma flare-ups that are often serious and occasionally life-threatening. It was after a teenager died from an asthma attack 13 years ago that the province moved to develop the Ontario Asthma Plan of Action “to reduce mortality, morbidity and health care costs… through integrated initiatives focused on health promotion and prevention, management and treatment, and research and surveillance.” One of those initiatives is the Emergency Department Asthma Care Pathway (EDACP), a standardized approach to the urgent treatment of asthma that was released by the Ontario Lung Association in 2008. Based on best practices, clinical pathways improve quality of care by promoting adherence to clinical guidelines, reducing variation in treatment and improving communication with the patient and among members of the health care team. Now the Lung Association has released the 2013 adult EDACP with a number of important updates including simplified physician’s orders; medication guidelines categorized as standard, nonstandard and discharge; and discharge instructions which can function as a prescription. To address possible treatment delays, the 2013 adult EDACP also includes an optional medical directive authorizing the administration of medi-

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cations to relieve asthma symptoms and reduce airway swelling prior to assessment by a physician. The adult EDACP is for patients 16 and older who have been diagnosed with asthma, chronic obstructive pulmonary disease (COPD) with asthma, or who have previously experienced wheezing that required treatment. The asthma care pathway recommends using lung function testing such as spirometry (preferred) or peak expiratory flow to guide treatment, as it can be difficult to accurately determine the severity of an asthma attack by symptoms alone. Another key feature of the adult EDACP is a patient education checklist which can be used by health professionals as a guide to providing important asthma education. Basic asthma “survival skills” such as using an inhaler correctly and recognizing signs of worsening asthma might prevent a repeat visit to the ED. The EDACP also promotes appropriate follow-up after the ED visit, such as an appointment with a primary care provider, asthma education centre or specialist depending on a patient’s needs and availability of local services. The EDACP, funded by the Government of Ontario as part of the Ontario Asthma Plan of Action, is available free for non-commercial use by not-for-profit health services organizations. For more information, visit www.on.lung.ca/edacp, email edacp@on.lung.ca, or call 416-8649911 (toll-free 1-888-344-5864), extenH sion 270. ■ Sandra Athron is provincial coordinator of the EDACP initiative at the Ontario Lung Association. www.hospitalnews.com


Focus 17

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

South pole trekkers to tell their tale at Summit By Heather Vita t’s not every day you meet someone who’s been to the South Pole. And it’s not every day you meet a heart transplant patient either. So when you meet someone who’s both a heart transplant patient and who’s been to the South Pole, you know you’re meeting someone special. People in Thunder Bay, Ontario, had just the chance to do that at the 2nd Annual Northwestern Ontario Cardiology Summit. This year’s summit opened with a dinner that featured Dale Shippam, a local firefighter and heart transplant patient, and his physician, Dr. Heather Ross. Guests heard the inspiring story about their recent trek to the South Pole – all in an effort to raise awareness for organ donation and transplantation. Dr. Ross is the leader of ‘Test Your Limits’, an expedition team that climbs mountains and treks to the ends of the world to raise awareness for heart failure research, cardiac transplantation and heart health. She is also a Professor of Medicine at the University of Toronto, Director of the Cardiac Transplant Program at Toronto General Hospital and is the Head of the MSH/UHN Heart Failure Program. Furthermore, she is the Ted Rogers and Family Chair in Heart Function. She says the inspiration for all their expeditions comes from Dale. “If a heart transplant recipient can complete the intense training and conquer these grueling

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(left to right) Dr. Michel White, Dr. Diego Delgato, Dr. Heather Ross & Dale Shippam, a local firefighter and heart transplant recipient, who reached the South Pole in January. Dr. Ross and Dale Shippam presented at the 2nd Annual Northwestern Cardiology Summit in Thunder Bay. treks to climb mountains and reach the Poles after surviving advanced stage heart failure, then anyone can do it.” The following day, the summit continued for healthcare professionals interested in hearing about the latest on heart failure management and palliation, device therapy, prevention and management of

hypertension, acute coronary syndromes, ECG abnormalities, cardiogenic syncope, exercise stress testing and other related topics. Nine leading cardiologists from across the country shared their expertise with attendees. The summit was made possible with the extraordinary support of sponsors in-

cluding the Northern Cardiac Fund of the Thunder Bay Regional Health Sciences Foundation, Sunovion, Bristol-Myers H Squibb. ■ Heather Vita is Marketing & Communications Coordinator with Thunder Bay Regional Health Sciences FoundationCanada, Eli Lilly Canada and Abbott.

JULY 2013 HOSPITAL NEWS


18 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

“Shari really made me feel like this was something I could do.”

Colette Therriault was motivated to quit smoking by Respiratory Therapist Shari Cole.

Supportive approach for smoking cessation at the North Bay Regional Health Centre By Lindsay Smylie Smith olette Therriault says she started smoking when she was 11 years old. “My brother and I were sitting on a dock and he wanted me to have a cigarette with him,” the mother of four says. “I remember coughing, but I also remember really liking it.” Colette started smoking that day, and smoked a half a pack a day (or

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more) until recently when she was an inpatient at the North Bay Regional Health Centre (NBRHC). Admitted to the hospital for other health problems, Colette says quitting smoking was not a priority for her at the time. But that was before she was visited by Respiratory Therapist Shari Cole, NBRHC’s Tobacco Intervention Clinical Coordinator. Shari visited Colette to perform a brief tobacco assessment as part of the

hospital’s Tobacco Intervention Program. “Patients who smoke, regardless of reason for admission or desire to quit, are visited by a Registered Respiratory Therapist (RRT) who has been trained in cessation,” Shari explains. First the patient is offered some nicotine replacement therapy to help with their cravings. “Depending on the patient’s feelings about their tobacco use, we can offer counseling, quit advice, and follow up through community links or Smokers Helpline,” Shari says. “Being in the hospital can be a time of motivation for someone to make a quit attempt.”

“Being in the hospital can be a time of motivation for someone to make a quit attempt.”

Colette and Shari review some of the supports available for patients interested in quitting smoking HOSPITAL NEWS JULY 2013

Shari says the majority of patients do not mind being asked about their tobacco use when it’s done in a nonjudgmental, supportive way. "Even patients who have no desire to stop smoking appreciate being offered nicotine replacements to help them stay comfortable,” she continues. “Sometimes, even the most dedicated smokers will change their minds after receiving the program supports.” NBRHC is unique because the RRTs, who are on duty 24/7, have been trained in cessation. Shari says this means the RRTs are able to assess the patient’s tobacco use, order the nicotine replacement and start the patient on the nicotine replacement

all in the same visit. “This not only allows the patient access to replacement sooner, but also gives the opportunity to educate the patient more on the products and how they work.”

Tobacco Intervention Program

After a brief pilot at the old North Bay General Hospital, the Tobacco Intervention Program has been offered on the Medicine, Surgery, Critical Care Unit, Pediatrics, and Long Term Care/ Long Term Rehabilitation units since the move to the new hospital site in 2011. The NBRHC program follows the “Ottawa Model”—which is a means of providing brief, best practice supports to patients who smoke, using a systematic, standardized approach. This involves identifying patients who use tobacco, and offering them nicotine replacement, information and resources. “Even though it is a short intervention, this process has been shown to increase quit rates by over 10 per cent,” Shari explains. The first few days Colette was in the hospital she had been too sick to smoke. After her assessment, Colette was offered nicotine replacement in the form of patches and inhalers. Colette had never tried using nicotine replacement before this program. “Right away I felt it was effective. The inhaler was very helpful for the hand to mouth part of the habit.” While Colette had tried to quit before, she had never tried to quit with the use of nicotine replacements before the program. The Ontario Mediwww.hospitalnews.com


Natural Path 19 cal Association recommends that any person attempting to quit smoking be offered stop smoking medications because these medications are shown to double a person’s likelihood of staying smoke free over the long term. Colette continued with the nicotine replacements during the two weeks she was an inpatient at NBRHC and she was able to abstain from smoking that whole time. Colette says she was worried about returning home after she was discharged. “I thought when I got back home that I would want to have a cigarette,” she says. Coping strategies she learned through the Tobacco Intervention Program to deal with the cravings and changing some behaviors made the transition easier. “It was important for me to keep a routine, but a new positive routine. Drinking cold water, crocheting and the delay method worked for me.” Shari says while the nicotine replacement is helpful for people as they work on quitting smoking, it is only a part of the process. “Colette, and people like her who are successful in quitting have a lot of work to do when it comes to managing cravings and overcoming the patterns that have been established from years of smoking.”

Supportive Approach

“We no longer just tell people they should quit smoking,” Shari says. “We give them the tools they need to help them be successful. It could be answering questions, providing recommended medications, or links to community resources. Stopping smoking is hard, and often takes more than one attempt or multiple supports.”

“We no longer just tell people they should quit smoking, we give them the tools they need to help them be successful.” It was the supportive approach that Colette credits with her success in quitting smoking. “Shari really made me feel like this was something I could do. She never made me feel bad for being a smoker. She told me she had some tools to help me stop smoking if that was something I wanted.” Colette has seen temptations on her quit journey, but says the key is to not get too upset if you have a slip. “You have to just look at it like it was a mistake, you’re only human and remind yourself you still want to quit. I feel very happy with how things have gone and I am looking forward to the day when I can call myself a non-smoker.” Shari is quick to point out to Colette that she already is a non-smoker. “Smoke from a cigarette contains some 4000 chemicals that Colette has not been exposed to since her last puff.” One of the best parts about quitting smoking for Colette is how proud her family is. The mother of four also has five grandchildren, one greatgrandchild and another on the way. She has been keeping cravings at bay by crocheting, and is working on a baby blanket for the newest addition to their family. “It’s an ongoing battle, it doesn’t really ever stop, not for me anyway.” But for Colette, it’s a battle H that is worth the fight. ■ Lindsay Smylie Smith is a Public Relations Consultant at North Bay Regional Health Centre. www.hospitalnews.com

Study shows treatment by naturopathic doctors may reduce cardiovascular risk By Catherine Kenwell dding naturopathic care to enhanced usual care may reduce cardiovascular disease among those at high risk, suggests a study conducted by the Canadian College of Naturopathic Medicine (CCNM) in conjunction with Canada Post Corporation (CPC) and the Canadian Union of Postal Workers (CUPW). Cardiovascular disease is the second leading cause of death in Canada. While lifestyle intervention is widely recognized as beneficial to its prevention, few individuals with, or at risk of cardiovascular disease receive intensive dietary and lifestyle counselling. Regulated naturopathic doctors in North America are trained in and emphasize this form of self-directed care. The results of the randomized controlled trial, published in the Canadian Medical Association Journal (CMAJ), is the first to rigorously examine the effectiveness of diet, health promotion advice, and strategic use of natural health products as delivered by naturopathic doctors to patients at risk of cardiovascular disease. The report demonstrates that naturopathic doctors may be an effective addition to health-care teams or to individuals struggling to make effective gains relating to cardiovascular health. “The support, knowledge and expertise of a naturopathic doctor to create an individualized approach to health and wellness achieves real, positive dietary and lifestyle changes, ultimately saving lives, improving quality of life, and preventing harmful diseases from manifesting,” says Kieran Cooley, BSc., ND, associate director of research at CCNM. This study was part of an innovative research and evaluation project on workplace health linking the Canadian Union of Postal Workers (CUPW), Canada Post Corporation (CPC), and the Canadian College of Naturopathic Medicine (CCNM). "It was an exciting partnership, creating a unique opportunity to work with a respected national employer and union, committed to examining what sort of impacts naturopathic medicine can have. The partnership helped create healthy employees and developed a work environment that fosters health," adds Cooley. Participants in the naturopathic group experienced a reduced 10-year cardiovascular risk profile and a lower frequency of metabolic syndrome compared to the control group who received only enhanced usual care. Researchers screened 1125 workers at Canada Post across three sites -Toronto, Vancouver and Edmonton. Of those screened, 246 consenting participants aged 25-65 with highest relative risk of cardiovascular disease were randomized to the pragmatic clinical trial. Of the 246 active participants, 207 completed the year-long study. Participants in both groups received

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The report demonstrates that naturopathic doctors may be an effective addition to health-care teams or to individuals struggling to make effective gains relating to cardiovascular health. care from their family physicians; those in the naturopathic group also received health promotion counselling, nutritional medicine and/or dietary supplementation from regulated naturopathic doctors seven times during the year. Primary outcomes included the prevalence of metabolic syndrome (a risk factor for heart disease) and the Framingham 10-year cardiovascular risk score, (used to estimate risk of heart disease). For those who received naturopathic care, the 10-year cardiovascular risk as measured by the Framingham score decreased by 3.1 per cent—which translates into about three fewer people out of 100 with intermediate risk experiencing a serious cardiovascular event (e.g., heart attack, stroke or death) during the next 10 years. Researchers also found the prevalence of metabolic syndrome was reduced by 17 per cent over a year as compared with the control group, implying that one in six individuals receiving naturopathic care benefit by not developing metabolic syndrome over the course of a year.

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“I am delighted to have the results of this important study published in CMAJ,” says Bob Bernhardt, PhD, CCNM president and CEO. “This study demonstrates that personal healthcare counselling, involving targeted dietary and lifestyle interventions as provided by naturopathic doctors, can be effective in reducing the risk of strokes and heart attacks. My hope is that this information will contribute to treatment changes that will leave fewer Canadians suffering from the loss associated with sudden cardiac events.”

About the Canadian College of Naturopathic Medicine

The Canadian College of Naturopathic Medicine (CCNM) is Canada's premier institute for education and research in naturopathic medicine. CCNM offers a rigorous four-year, full-time doctor of naturopathic medicine program. The College educates, develops and trains naturopathic doctors through excellence in health education, clinical services and research that integrate mind, body and spirit. In Ontario, naturopathic doctors (NDs) are regulated health-care practitioners. Currently, the profession is transitioning to new regulation within the Regulated Health Professions Act. Visits to naturopathic doctors are typically half an hour or more in length, and involve standard medical diagnostic assessments as well as a range of therapies including lifestyle counselling, nutrition, botanical medicine, acupuncture/Asian medicine, homeopathic H medicine, and hydrotherapy/massage. ■ Catherine Kenwell is director, marketing and communications at the Canadian College of Naturopathic Medicine.

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JULY 2013 HOSPITAL NEWS


20 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

Building a community of stroke care By Sybil Edmonds, Sylvia Quant, Nadia Radovini and Sharron Runions Patients at Sunnybrook Health Sciences Centre have always had access to exceptional care after experiencing a stroke. A new initiative has been making that patient experience even better. Last fall, as a Regional Stroke Centre, Sunnybrook’s stroke services began its implementation of the Toronto Stroke Networks’ Transition Improvement for Continuity of Care (TICC). This multisite initiative aims at improving communication between acute care, rehabilitation and the community, with the ultimate goal of improving patient experience and outcomes for those living with stroke. “Stroke recovery is a complex process that involves extensive coordination through the care continuum and over time,” says Beth Linkewich, Director of the North & East GTA Stroke Network and Regional Stroke Centre at Sunnybrook. “It is critical for us to identify and support transitions with the current changes in service delivery to ensure access to timely and appropriate stroke care, including interprofessional stroke units, intense rehabilitation, and outpatient programs. TICC is the glue that holds the system together.”

As part of the implementation of TICC at Sunnybrook, the C4 Stroke Unit team at the Bayview campus organized a successful TICC education retreat for front line staff. This photo illustrates collaborative change leadership amongst TICC champions and front line staff. “Implementing TICC has helped us strengthen our relationships with rehab facilities around the Greater Toronto Area

and makes for a more streamlined transition process from acute care to rehabilitation,” says Jeff Upshaw, patient care man-

Sunnybrook leads in TAVI expertise, research and training Procedure treats severely damaged aortic valve By Marie Sanderson ince its inception in 2009, Sunnybrook’s Schulich Heart Centre’s TAVI program has provided access to a lifesaving heart procedure for 180 elderly or frail patients not well enough to undergo traditional aortic valve replacement surgery. Now, the centre is sharing its expertise with other Canadian centres to ensure that patients across the country have access to the less invasive procedure. Transcatheter Aortic Valve Implantation, or TAVI, addresses the narrowing of the aortic valve, or “stenosis”, a fairly common condition in today’s aging population. If left untreated, stenosis can cause the heart muscle to thicken as it works harder to pump blood through the body, potentially leading to heart failure. TAVI at Sunnybrook is a team effort, with an Interventional Cardiologist, Cardiac Surgeon, Vascular Surgeon, cardiac imaging experts, cardiac anaesthesiologist, as well as Cath Lab nurses, all working together to implant a new valve percutaneously (without opening the patient’s chest). The procedure takes two to three hours, about half as long as conventional open-heart surgery for these complex patients, and may be carried out under general or local anaesthesia, with or without sedation. Benefits to patients include reduced pain and less need for postoperative pain medication, smaller scars, a shorter stay in the hospital and a faster recovery. Under the leadership of Dr. Sam Rad-

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HOSPITAL NEWS JULY 2013

A TAVI valve used at Sunnybrook. The life-saving procedure has treated 180 patients at Sunnybrook who suffer stenosis, or narrowing of the aortic valve. hakrishnan, Director of the Cardiac Cath Labs and Physician-Lead of Sunnybrook’s TAVI program, the hospital is guiding training for other Canadian hospitals to initiate their own TAVI programs. “It’s a priority to continue our leadership role in research and training for TAVI. In addition to helping to establish TAVI programs in London, Kingston and Victoria, we’re also teaching new techniques to a mature TAVI program in Quebec. Dis-

seminating this knowledge across Canada will greatly improve the health of some of the most critically ill heart patients in the country,” says Dr. Radhakrishnan. When Sunnybrook first started performing TAVI, the procedure was unfunded, so the hospital developed its expertise thanks to generous donations to the Sunnybrook Foundation, with each case costing approximately $35,000. In January 2013, Sunnybrook was approved by the Ontario Ministry of Health and Long-Term Care to proceed with 75 fully funded procedures for the 2013 fiscal year. Sunnybrook is one of only six programs in the province to be provided with Ministry TAVI funding and the expectation is for growth of the program to 90 cases in 2014. Sunnybrook will continue to submit data to the Cardiac Care Network on TAVI outcomes. For patients like Margery Brennan, a 72-year-old who wasn’t able to stay by herself as she had difficulty walking, life before TAVI simply “wasn’t good.” Margery underwent TAVI in December 2012 and says, “My heart went right back to normal, I felt like a brand new person. Now I’m able to do my own housework and have a new lease on life.” Like many TAVI patients, Margery returned home after only a few days and resumed many of her normal activities within a couple of weeks rather than a H couple of months. ■ Marie Sanderson is a Senior Communications Advisor at Sunnybrook Health Sciences Centre.

ager at Sunnybrook’s Acute Stroke Unit on C4 of the Bayview campus. The stroke team from Sunnybrook’s newest program area, St. John’s Rehab, also participates in this quality improvement initiative: “Through TICC, we have been able to open the lines of communication with our acute care partners and therefore ease our patients’ transition through the continuum of care,” says Jennifer Moebs, occupational therapist at St. John’s Rehab’s A3 Neurology and Oncology Rehab Program. As part of TICC, three pilot projects were introduced in the fall and winter of 2012/2013 to help support transitions through the stroke patient’s care journey. Each project was developed from the results of interviews conducted with persons with stroke and their caregivers and include the following:

1) My Stroke Passport:

A patient-mediated communication and navigation tool (in the form of a binder) that facilitates seamless, holistic and meaningful care for persons with stroke and their caregivers. The tool supports patient self-management, education and care collaboration between the patient/caregiver and healthcare providers. Specifically, it helps patients manage their own care by keeping track of their health, recovery, goals and rehab plans as they move between hospitals and the community. It also includes a resource guide that provides information on stroke-related services.

2) Knowing Each Other’s Work (KEOW):

A series of initiatives for healthcare providers from various disciplines to build on relationships, foster learning, and enhance meaningful collaboration and communication across the system to know each other’s work. By learning from each other’s practice environments, KEOW enables healthcare providers to deliver the most seamless and optimistic care possible for people living with stroke throughout their journey and across the continuum of care. Continued on page 30 www.hospitalnews.com


Focus 21

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

The Bloorview Research Institute is starting the conversation:

Obesity in Children with Disabilities By Claire Florentin hildhood obesity is a big topic in the news lately, but did you know that children with disabilities are even more likely to struggle with weight issues? Dr. Amy McPherson, a scientist at the Bloorview Research Institute at Holland Bloorview Kids Rehabilitation Hospital, conducts research to better understand weight communication, assessment and management for children with disabilities. Dr. McPherson and her team recently received funding from the Spina Bifida and Hydrocephalus Association of Canada (SBHAC) to conduct research in weight management for children with spina bifida. Dr. McPherson hopes that the findings will enable her to provide guidance for conversations about weight and well-being between healthcare providers, families, and children with disabilities. Children with spina bifida and other disabilities are at a particularly high risk of obesity, which can in turn worsen their condition, lead to new medical problems, and limit their quality of life. Overweight children with disabilities also risk high blood cholesterol, increasing the risk of cardiovascular disease in adulthood. Dr. McPherson first began looking at weight-related issues in the spina bifida population when she conducted a review of medical charts in 2011 which suggested that weight was not a priority issue in many conversations with clients and their families. This was followed by a study in 2012 that surveyed healthcare providers across Canada to understand how they were measuring weight in kids with spina bifida, and just as importantly, how they talked about weight management with these clients.

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The findings from this first survey study led Dr. McPherson to develop her current study entitled “How Should We Talk About Weight-Related Issues in Spina Bifida Consultations? Perspectives from Children, Families, and Healthcare Professionals.” With this work, Dr. McPherson hopes to move beyond just describing participant experiences to developing more appropriate tools and techniques that can help healthcare providers feel more comfortable raising the important issue of weight. “The feedback I have got from healthcare providers so far has been invaluable.

Now, we are going to use that feedback, along with the views of children and families, to develop guidance around measuring and discussing weight in kids with disabilities,” said Dr. McPherson. “Maintaining a healthy weight is incredibly important for all children, and we want to ensure that healthcare providers, clients, and families are comfortable working together to help achieve that goal.” For more information on this study, contact Amy McPherson in the Bloorview Research Institute at amcpherson@hollandbloorview.ca.

The Bloorview Research Institute

The Bloorview Research Institute is located onsite at Holland Bloorview Kids Rehabilitation Hospital, Canada’s largest children’s rehabilitation teaching hospital. The Bloorview Research Institute is the only hospital-embedded pediatric reH habilitation institute in Canada. ■ Claire Florentin is a Communications Associate at Holland Bloorview Kids Rehabilitation Hospital

“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

Children with spina bifida and other disabilities are at a particularly high risk of obesity, which can in turn worsen their condition... “When we asked healthcare providers how they were assessing and discussing weight with their clients with spina bifida, we got consistent feedback that better options were needed,” explained Dr. McPherson. Her findings showed that healthcare providers in pediatric spina bifida clinics were dissatisfied with the methods currently at their disposal to assess weight in children with spina bifida. Traditional techniques like Body Mass Index don’t work well for children with a different body composition, and the healthcare providers expressed interest in new weight assessment tools developed specifically for children with certain disabilities. Dr. McPherson was also surprised to find that weight was not routinely discussed with children and their families. The reason for this became clear as she looked at the data: only 25 per cent of healthcare providers rated themselves confident to discuss weight-related issues with these patients. www.hospitalnews.com

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.

YOUR ADVANTAGE, in and out of the courtroom

416-868-3100 | 1-888-223-0448 www.thomsonrogers.com JULY 2013 HOSPITAL NEWS


22 Nursing Pulse

Nursing order sets standardize care From the Crowd! across sectors, ĚǀĞƌƟƐĞŝŶŽƵƌ^ƉĞĐŝĂů^ĞĐƟŽŶ geographical areas

Stand Out

By Rita Wilson or decades, the Registered Nurses’ Association of Ontario (RNAO) has been helping nurses provide the best care possible to their patients or clients. RNAO reviews the latest research evidence on nursing interventions that produce the highest quality health outcomes, and publishes this information in its best practice guidelines (BPG). Hundreds of health-care organizations – nationally and internationally – have implemented RNAO BPGs since they were first introduced in 1999. There are currently 48 BPGs; nine of which focus on healthy work environments, and 39 on clinical practice. RNAO BPGs were originally designed to be used in environments with paper-based health-care records and clinical resources. Increasingly, however, hospitals and other health-care organizations are using computerized equipment to improve care. RNAO has kept pace with this new trend by developing ‘nursing order sets’ to help hospitals and other health-care organizations to more effectively foster a culture of evidence-based nursing practice.

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Nursing order sets use a consistent language, called the International Classification of Nursing Practice (ICNP®), to describe the care that nurses provide regardless of the setting. Nursing order sets are BPGs that have been converted into specific, action-oriented nursing interventions that can be embedded within a clinical information system or paper-based tool. These order sets help to standardize the care provided for a specific patient or client condition, such as pressure ulcers or pain. They also make it easier for nurses to access the best evidence to inform their practice, whenever and wherever they need it. Ontario’s North West Local Health Integrated Network (LHIN) is the first organization in Canada to implement RNAO’s nursing order sets in 12 hospitals within its jurisdiction. The initiative is funded by the Small, Rural, and Northern Hospitals Transformation Fund, introduced by Ontario’s Ministry of Health at the beginning of April 2013. A total of $20-million is available to help small and rural hospitals across the province improve the quality of care for patients in their communities. Geographically, the North West LHIN covers the largest health region in the province.

It serves the largest Aboriginal population by proportion. And it works proactively with health-care providers, communities and the public in northwestern Ontario to set health-care priorities. It also provides oversight for the integration and co-ordination of local health-care services to ensure that patients have access to the care they need, and clinicians have access to the information they need to provide high quality care. Like the 12 hospitals involved in this initiative, other health-care organizations will derive many benefits from implementing nursing order sets, whether they focus on acute care, home care, long-term care or community care. For example, it takes approximately 17 years for research findings to become a routine part of a nurse’s day-to-day practice. By embedding RNAO’s evidencebased nursing order sets within clinical information systems and electronic medical records, nurses will immediately have access to the best available evidence at their fingertips, to inform their practice. Nursing order sets use a consistent language, called the International Classification of Nursing Practice (ICNP®), to describe the care that nurses provide regardless of the setting. Using a consistent language like ICNP will standardize nursing practice, making it easier for researchers to study the effect of specific interventions on health outcomes, and to compare the results across healthcare sectors and geographical areas. This information will be useful for both nurses and policy-makers. RNAO has partnered with Patient OrderSets.com on this project, a leading provider of order sets in Canada with a client base of over 245 health-care organizations. There are two implementation options: TxConnect and EntryPoint. Both are webbased applications. TxConnect allows health-care organizations to adapt the nursing order sets to their clinical context and print them as needed for inclusion in a patient’s or client’s paper-based health record. EntryPoint allows organizations to complete the order sets electronically using a desktop computer or mobile tablet. For more information about nursing order sets, visit www.RNAO.ca or contact H rwilson@RNAO.ca ■ Rita Wilson, RN MN Med is eHealth program manager for the Registered Nurses’ Association of Ontario (RNAO). Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses’ contribution to shaping the health-care system, and influenced decisions that affect nurses and the public they serve. To find out more, visit www.RNAO.ca www.hospitalnews.com


Focus 23

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

Diabetes researchers battle the fastest growing global epidemic of the 21st century “By 2030, about 500 million people worldwide will be affected by diabetes. Unfortunately, diabetes has become the disease of the 21st century, and it will surpass the health and economic implications of AIDS.” – Dr. Bernard Zinman, Director of Mount Sinai’s Leadership Sinai Centre for Diabetes and Senior Investigator at the Samuel Lunenfeld Research Institute By Sandeep Dhaliwal ount Sinai Hospital’s Samuel Lunenfeld Research Institute is ranked #1 world-wide for diabetes research compared to other medical research institutes. That is why, on June 17, 2013, Mount Sinai hosted top diabetes researchers from around the world at the 2013 International Frontiers in Diabetes Research symposium. Here, leading researchers shared their latest breakthroughs in diabetes research that have the potential to transform care for more than 250 million patients worldwide suffering from this spiralling epidemic. According to the Canadian Diabetes Association, more than 20 people are newly diagnosed with the disease every hour of every day in Canada alone. Mount Sinai researchers and clinicians are working with their colleagues around the world toward an increased global understanding of this chronic disease so that patients can better manage and control this disease. Ideally, researchers are looking for ways to prevent diabetes before it even starts – but once it does, researchers are striving to halt the disease in its early stages. Mount Sinai researchers made news headlines last year around a new treatment which involved having non-insulindependent, type 2 diabetics take four shots of carefully-dosed insulin per day for one month, allowing patients to achieve a temporary remission. Now, researchers are looking to halt diabetes permanently, similar to how cancers can be forced into permanent remission. Recently, a new trial launched at Mount Sinai Hospital aims to demonstrate that when introduced early in the course of disease, treatment with short-term insulin therapy for two to three weeks can actually help restore the body’s ability to make and respond to insulin, the two key deficits that cause diabetes, and even reverse the disease. Called RESET IT (Remission Studies Evaluating Type 2 Diabetes – Intermittent Insulin Therapy), the new clinical study will potentially impact future therapy guidelines for the course of treatment typically prescribed to diabetes patients. The study is led by Dr. Ravi Retnakaran,

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www.hospitalnews.com

Endocrinologist at Mount Sinai’s Leadership Sinai Centre for Diabetes and an Associate Scientist with Mount Sinai’s Samuel Lunenfeld Research Institute. Currently, insulin therapy is usually the last option in the course of treatment for patients, by which point in the disease the beta cells in the pancreas, which produce insulin, have worsened beyond repair. The new study hypothesizes that patients should be treated earlier with insulin for a short period of time in order to preserve the function of beta cells and thus alter the normal progression of the disease. “Traditionally, by the time the patient is prescribed insulin therapy to treat diabetes, it's too late to reverse the disease process,” explains Dr. Ravi Retnakaran. “When we treat patients temporarily with intensive insulin therapy for three weeks

Dr. Ravi Retnakaran, Mount Sinai Hospital endocrinologist and scientist, with diabetes patient Tulsi Ram Upadhay. Upadhay, 44, discovered he had diabetes during a routine physical in 2009. early in the course of disease, it is possible to improve the ability of the body to make and use its own insulin.” At the recent June 17 diabetes symposium at Mount Sinai Hospital, experts from other leading diabetes research institutions such as Harvard Medical School, Yale University School of Medicine, and

At some point, everyone can use a hand.

the Universities of Texas and Cincinnati, presented their latest breakthroughs in basic diabetes biology as well as new therapies and treatments in hopes of curbing H this growing 21st century epidemic. ■ Sandeep Dhaliwal is a Communications Specialist at the Samuel Lunenfeld Research Institute.

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JULY 2013 HOSPITAL NEWS


24 From the CEO's Desk

Taking a long look in the rearview mirror can build momentum for the future By Elisabeth Riley

s leaders, we must keep a steely focus on the future of our organizations as we continually strive toward our objectives amidst the whirlwind of day to day activity. Streams of data grab our attention with greater frequency than ever before; without taking the occasional step back, one can lose the big picture perspective that only time can provide. I was recently reminded of the importance of taking that long look back as our team took a moment to reflect on our Hospital’s journey over the past five years. Like many hospitals in Ontario, Orillia Soldiers’ Memorial Hospital (OSMH) has spent the past several months struggling to find ways to balance our 2013/14 budget while maintaining services and our commitment to our values and to safe, quality care. The hurdle for us was even higher as OSMH is currently participating in the provincial Working Capital Relief program that requires us not only to balance, but to achieve a surplus equal to one percent of our total budget.

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Our goal is to provide the right care in the right place and to improve patient flow throughout the hospital. While we’ve been successful in building a plan to achieve our objectives, it wasn’t easy. And it won’t be easy in the months to come. There are impacts to staff and many changes with the most significant being a reduction in the number of beds. We are also moving forward with process changes that require a cultural shift in the organization and in the community. The primary change revolves around the designating of patients as ALC (Alternate Level of Care) to Long-Term Care, a practice that was quite common before but often led to lengthy hospital stays for ALC

Elisabeth Riley patients. By working more closely with patients, families, physicians, care teams, CCAC and other health and social service providers, we are in many cases able to avoid those designations. We assist patients to get care at home or quicker access to other community resources. Our goal is to provide the right care in the right place and to improve patient flow throughout the hospital. We learned from other successful organizations and will now only designate a patient as ALC to Long Term Care with Senior Team involvement. We have patient navigators who work with the CCAC to avoid admissions and expedite discharges. We have already seen early encouraging results with fewer ALC patients, many days with zero admitted patients waiting in the ED and empty beds which will soon be closed as part of the plan to balance the budget. With change comes uncertainty and doubts from the staff and the community, “Is this plan doable?” When we started to look back we realized that the gains our hospital had made over the past five years were really quite remarkable, and the evidence was all there in front of us in the form of performance indicators, balance sheets and external feedback. From a financial perspective, the hospital posted four consecutive deficits from 2007/08 to 2010/11 and struggled with an

accumulated debt in excess of $25 million. Today, we’ve just completed two years in the black, reduced our debt by nearly $7 million and are on track for nearly $10 million more in debt relief in the years ahead. For the first time in the past several years, the hospital’s Total Margin (deficit surplus) is better than the average of Large Community Hospitals in Ontario. Starting with Board leadership, steady and significant improvement in Quality and Safety is also clearly reflected in the results of our past three Accreditation surveys. In 2007, our hospital met just 65.5 per cent of 180 patient safety standards. By 2010, in an analysis of approximately 2,000 standards, OSMH achieved a score of 91.5 per cent, which improved to 96.8 per cent by JULY 2013, and led surveyors to comment how they would all enjoy working or having a loved one cared for here at OSMH. Participating in Accreditation surveys enables hospitals to evaluate their performance against national standards of excellence, and is seen as one of the most effective ways to improve quality. We’re also showing improvement in many of our publicly reported indicators, most notably, hand hygiene where are compliance has shifted dramatically from just over 50 per cent in 2008/09 to consistently over 80 per cent over the past year and a half. Our surgical safety checklist compliance moved from 85 per cent in 2010 to more than 97 per cent today and our HSMR (Hospital Standardized Mortality Ratio) has moved significantly below the 100 plateau on a consistent basis. Of course, none of our success would have been possible without the Board, leaders, physicians and front line staff who have chosen to be part of the work of performance improvement and focus on goals. The true barometer of successful change is what happens at the front line of care. After a significant organizational change in 2007/08, the hospital needed time to rebuild trust within the organization and the community and we were grateful to receive the Silver Quality Healthcare Workplace award from the OHA for the past two years in a row. So, to what do we attribute our progress? The adage ‘how can you expect different results if you keep doing things

the same way’, certainly applies. Starting with sound principles of governance, the Board of today looks very different as a skills-based board with a high functioning committee structure. As an organization we started doing things differently by becoming one of the early hospital adopters of Performance Improvement based on LEAN methodology and most importantly the recognition that as leaders we needed to change how we lead.

The true barometer of successful change is what happens at the front line of care.

Much of our recent change has revolved around the book ‘The 4 Disciplines of Execution’ and are now into our second year of identifying WIGS (Wildly Important Goals), along with the appropriate lead and lag indicators to influence them. One of the clear lessons learned has been to limit the number of WIGS to just two or three. An organization with too many big goals will have limited success at best. Aligning your WIGS to the strategic plan is critical. Build on past successes or “Do more of what got you there,” is a quote from the book ‘Peaks and Valleys’, a valuable book that teaches the reader to get out of valleys sooner and stay on the peaks longer. Recognizing the variables that influenced your peaks and applying them to new challenges can also improve results. The changes today are achievable because of the solid foundation built over the past few years both within the hospital and in the enhancements to the Home care and Community Sectors. Sharing this can be a real eye-opener for the community and the hospital as we face this new and H challenging fiscal environment.■ Elisabeth Riley is President and CEO of Orillia Soldiers’ Memorial Hospital.

How can I control my asthma this summer vacation?

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ummer has arrived, and many Canadians will be heading to their favourite vacation destination for some fun and

relaxation. However, for those with asthma, there are things to keep in mind before packing your bags. Dr. Chapman, a respirologist at University Health Network in Toronto, shares his expert advice. Q. Dear Dr. Chapman: I've been living with asthma for years and the pollution and summer heat in the city has made my asthma act up in the past, causing me to wheeze and be short of breath. I'm planning a summer vacation to a cottage by the lake and I'm really looking forward to getting away and into the fresh air. HOSPITAL NEWS JULY 2013

Is there anything in particular I should do to prepare? A. We all look forward to taking a break to enjoy great summer weather, especially if we can get away to cottage country. But while you may think country air is easier to breathe than city air, allergens found in the great outdoors or other vacation destinations can sometimes make you more prone to asthma attacks. Doctors consider asthma to be a chronic disease – meaning that it doesn't come and go but is always present. Asthma may make it difficult to breathe when you are around allergens, such as mold in a cottage, dust in a hotel room, or pollen from flowers or trees. When exposed to allergens, lung airways may become inflamed, filling with

mucus and causing difficulty in breathing, resulting in an asthma attack that might even require hospitalization. The good news is there is a simple step you can take to help control your condition and breathe more easily while you're away – pack your asthma medication and always take it as prescribed by your doctor. This means taking your daily maintenance medication even when you are symptom-free. As well, before any travel, including summer vacations, make sure that you have a written action plan developed with your doctor. This plan is a description of medication changes and other actions to take if your H asthma worsens unexpectedly. ■ www.newscanada.com

While you may think country air is easier to breathe than city air, allergens found in the great outdoors or other vacation destinations can sometimes make you more prone to asthma attacks.

www.hospitalnews.com


Focus 25

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

Dr. Chris Lai, cardiologist at Thunder Bay Regional Health Science Centre, is part of the team that celebrated 25 years of the Cardia Cath Lab.

Cardiac cath lab celebrates 25th anniversary By Marcello Bernardo he Thunder Bay Regional Health Sciences Centre (TBRHSC) recently celebrated 25 years of Cardiac Catheterizations in Northwestern Ontario. Current members of the TBRHSC Cardiac Catheterization team, along with members of the original team of 1988 were on hand to mark the occasion. Since February 1988, approximately 27,000 patients have received cardiac catheterization services in Thunder Bay.

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“Our successful past will shape an equally remarkable future for cardiac care at TBRHSC." “Through the efforts of our respected TBRHSC cardiac professionals and the financial support of the Thunder Bay Regional Health Sciences Foundation, tremendous strides have been made in cardiac care,” said Dr. Mark Henderson, Executive Vice President, Chronic Disease Prevention and Management, TBRHSC. “Our successful past will shape an equally remarkable future for cardiac care at TBRHSC." The quality of cardiac care in Northwestern Ontario has steadily improved over the last 25 years: In October 2007, Northwestern Ontario‘s first angioplasties were performed at TBRHSC‘s cardiac catheterization lab; the introduction of which allowed patients www.hospitalnews.com

to have the procedure done close to home, saving expenses and stress that would have been incurred in travelling to southern Ontario. A second cardiac catheterization lab opened in August 2011. Before it opened, the lab provided angioplasty services to 250 patients per year. After it opened, that number expanded to over 600 per year. The success of the local Cardiac Catheterization program led to the development of the first Visiting Cardiac Surgical Clinic Model in Ontario, which became a model for other hospitals. In September 2012, a fourth angioplasty specialist joined the TBRHSC team of cardiologists. There are now a total of four interventional cardiologists and two that perform catheterizations. In the past five years alone, TBRHSC has served cardiac patients in Northwestern Ontario by performing 9,600 cardiac catheterizations, 2,850 angioplasties, and 1,000 pacemaker implants. This strong history paved the path for a bright future for TBRHSC. Donors across the region, through the Thunder Bay Regional Health Sciences Foundation, have contributed millions of dollars towards vital cardiac equipment, making these advances in cardiac care possible. “Because of a vision for expansion, and a community that supported that vision through donations to the Northern Cardiac Fund, cardiac care in Northwestern Ontario looks a lot different than it did just a few short years ago,” said Vince Mirabelli of the Thunder Bay Regional Health SciH ences Foundation Board of Directors. ■ Marcello Bernardo is a Communications Officer at Thunder Bay Regional Health Sciences Centre in Thunder Bay, Ontario.

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JULY 2013 HOSPITAL NEWS


26 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

Home sweet home Enhanced Living Service gives patients more independence By Mark Palmer

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or some patients in our healthcare system, the hospitals in which they are treated and cared for function almost as their permanent homes. But “home life” for those patients, with its clinical characteristics, doesn’t resemble what able-bodied people are used to. West Park Healthcare Centre is trying to change that for some of its complex continuing care respiratory patients with the introduction of the Enhanced Living Service (ELS). Opened in early October 2012, the ELS is situated in a building separate from the main hospital building on West Park’s campus and features a more home-like setting with four apartments (two single and two double) to accommodate six current patients with issues requiring Chronic Assisted Ventilatory Care (CAVC). Made possible with funding through the Toronto Central LHIN, the ELS space includes a communal family room and a kitchen area for entertainment and meal preparation as well as direct access to the outdoors on West Park’s 27-acre campus. The comfort of a warmer, less clinical environment is bolstered by the care that Client Care Attendant staff provide 24/7 from an adjacent workstation. Patients are also able to direct their own care and the service enables patients to transition back to the community.

"You get to know your fellow patients better… I don't feel like I'm in a hospital." For patients Deidre Samuels and Pat Godin, the new service offers the best of both worlds. “We have more freedom and independence, and it’s less noisy and hectic than the old unit we were on,” says Samuels, who has been at West Park for eight years. Pat Godin, Samuels’ roommate, says the ELS accommodates a more independent, social lifestyle.

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Donna Renzetti, West Park VP Programs officially opens the Enhanced Living Service at an open house last year. “We can dine together as a group, socialize, and use the computer. You get to know your fellow patients better,” Godin says. “I don’t feel like I’m in a hospital.” Godin also is careful to point out other elements of the ELS and hospital as a whole that add to their more independent lifestyle. “We have our own private showers

in each room and drawers for our personal things. We can also access the hairdresser at the Long-Term Care Centre (next door) and now the new (retail) pharmacy (in another nearby building).” There are other exciting things afoot at the ELS. There are plans to create an ELS garden, and on May 29, ELS residents or-

ganized an art show called Rejuvenation, with art supplied by the students of Etobicoke’s Martingrove Collegiate Institute. Much of the art created will remain on the walls of the ELS and will be rotated regularly with other art. The new relationship with Martingrove Collegiate will include future visits to the secondary school for art shows and other events. Judy Gargaro, a West Park Clinical Program Evaluator conducted a clinical evaluation of the ELS after it opened and found, in interviews with ELS patients, that even though they were very happy with the new space, it needed more of an identity. “Many of the patients were artists and suggested having art on the walls,” Gargaro says. “I suggested student art and they really liked the idea.” The new surroundings with its homelike atmosphere has created a palpable atmosphere of camaraderie in the ELS. “I love it here,” says Samuels. “It’s a great H space and I have a great roommate.” ■ Mark Palmer is a Communications Specialist at West Park Healthcare Centre.

Cardiac rehab helps other chronic conditions By Graham Strong es, cardiac rehab after a heart event is important in a patient’s recovery. But prevention is even better. That’s why the Cardiac Education and Rehabilitation Program at the Thunder Bay Regional Health Sciences Centre would like to expand programming to include high-risk clients to help them delay or avoid heart events. The program has already accepted patients with other chronic conditions or with multiple risk factors into the program as a preventative measure. “Our mandate is cardiac rehab, but we’d like to expand that to encompass all chronic conditions,” said Caterina Kmill, Cardiac Rehab’s Program Coordinator. “It makes a lot of sense. In my 13 years in this program, I don’t remember a patient that has just cardiac disease – they have other health issues. We know that this type of programming can help with those health issues and reduce risk factors.” Although physical exercise plays a large role, the program is a holistic approach for clients and includes a variety of lifestyle changes to help clients get healthy such as education, diet and eating information, and one-on-one coaching. “Every client has a personalized exercise program with us,” Kmill said. “We encourage our clients to set goals and then we help them work towards it.” These goals may include losing weight, decreasing fatigue, and regaining that sense of vitality. It might be as simple and specific as wanting to play with their grandchildren again without being exhausted at the end of the day. “The focus is to change health behaviours: increasing activity, stopping smoking, improving diet and nutrition, reducing alcohol consump-

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Kinesiologist Kyle Baysarowich and Program Coordinator Caterina Kmill are part of the team with Thunder Bay Regional Health Sciences Centre’s Cardiac Education and Rehabilitation Program. tion, and so on,” she said. In Thunder Bay, the Cardiac Rehab program itself usually has about 200 clients at any given moment – it has room for up to 400 – and gets about 850 referrals per year. There are also eight partner sites in the region: Atikokan, Dryden, Fort Frances, Geraldton, Manitouwadge, Marathon, Nipigon, and Sioux Lookout – programs in two other communities may also open in the near future. Cardiac Rehab offers Tele-rehab services including education and information sessions via videoconferencing to reach clients across Northwestern Ontario. Thanks at least in part to its successes, the program is part of a study with Toronto Rehab to measure exactly how the Cardiac Rehab program improves Quality of Life for its clients, and may be part of a second study investigating the impact of exercise on chronic illness.

Kmill said that exercise is the single best thing a person can do to improve their health – before or after a heart attack.“We know that one bout of exercise will lower blood pressure for hours and your blood glucose goes down,” Kmill said. “After regular exercise, you’re looking at changes like your skeletal muscle mass improving, weight loss, and a smaller waist as people lose that visceral fat.” Making healthy food choices, avoiding stress, and of course stopping smoking are also important – and the earlier the better. “Medication and medical treatments after we’ve developed these chronic conditions isn’t the answer. We want to help clients avoid these conditions in the first H place,” Kmill said. ■ Graham Strong is a Freelance Writer working with Thunder Bay Regional Health Sciences Centre. www.hospitalnews.com


Patient Safety 27

Thromboprophylaxis Are your patients receiving correct care 100 per cent of the time? By Hugh MacLeod Meet Mary. She is a 61-year-old working artist who, apart from leg pain and limitations due to osteoarthritis of her hips and knees, is considered to be healthy. After years of progressive pain, Mary decided to undergo knee arthroplasty. Despite her positive attitude going into surgery, Mary developed major bilateral pulmonary emboli a few days after she was discharged from hospital. A pulmonary embolism is when an abnormal blood clot (thrombosis) forms inside a vein deep in the leg, causing leg pain and swelling. A blood clot in a leg vein can grow, break off, and travel to the lungs, resulting in shortness of breath, chest pain, and in some cases, death. Venous thromoboembolism (VTE), which comprises both deep vein thrombosis and pulmonary embolism, is one of the most common and preventable complications of hospitalization. Almost every hospitalized patient has at least one of the risk factors for VTE and most have multiple risk factors. Mary’s marked shortness of breath and chest pain slowly resolved over several weeks after starting anticoagulant therapy. However, she felt alone in trying to understand the cause of her distressing symptoms and why better thromboprophylaxis had not been used in her case. She is now reluctant to have more surgery because of her near fatal event.

Venous thromoboembolism (VTE), which comprises both deep vein thrombosis and pulmonary embolism, is one of the most common and preventable complications of hospitalization.

Mary hopes that healthcare providers will take serious “steps towards a healthier and safer public environment” by understanding the risks for deep vein thrombosis and pulmonary embolism and providing appropriate thromboprophylaxis for patients who are at risk. Every year in Canada, thousands of people go through procedures just like Mary. The rate of hospital-acquired VTE, if a thromboprophylaxis is not used, is 10–40 per cent after general surgery and 40–60 per cent after major orthopedic surgery. According to an evidence report prepared for the Agency for Healthcare Research and Quality in the United States, the appropriate use of thromboprophylaxis was the most highly rated of 79 safety practices based on its impact and effectiveness and was, therefore, considered to be the number one ranked patient safety practice for hospitals. www.hospitalnews.com

In addition to the acute consequences of hospital-acquired VTE, there are also important long-term complications to consider. At your hospital, do 100 per cent of hospital patients at risk for VTE receive appropriate thromboprophylaxis 100 per cent of the time? If not, you’ve definitely got some work to do. But don’t worry, you’re not alone and we can help. Canadian VTE Audit Day was held on April 10 to establish a national perspective of thromboprophylaxis rates and to raise awareness about this key patient safety strategy. We were thrilled to see 118 organizations submitted data on VTE thromboprophylaxis rates for 4,667 patients. Overall, the data indicates that 81 per cent of patients did receive appropriate thromboprophylaxis. This generally represents good news but, since 19 per cent of the patients at risk did not receive appropriate thromboprophylaxis, the national audit also demonstrates that there is definitely room for improvement. In addition to the acute consequences of hospital-acquired VTE, there are also important long-term complications to consider. For instance, both deep vein thrombosis and pulmonary embolism require anticoagulation for at least several months and patients who develop VTE are more likely to have recurrent thromboembolic events in the future. These and other complications represent substantial costs in terms of patient quality of life and healthcare resources. To assist organizations in ensuring their patients are receiving appropriate thromboprophylaxis 100 per cent of the time, Safer Healthcare Now! offers a free Getting Started Kit on VTE in both French and English to help engage interprofessional and interdisciplinary teams in a dynamic approach for improving quality and safety. The Getting Started Kit for VTE, which was last updated and published in May 2012, represents the most current evidence, knowledge and practice, as of the date of publication. Patient Safety Metrics, an online measurement and data collection tool, is also available to assist teams with their auditing and improvement efforts. Along with the Getting Started Kit and Patient Safety Metrics, Safer Healthcare Now! provides access to a number of supports and resources to assist local teams in improving patient safety and quality. For the sake of Mary and the thousands like her, visit www.saferhealthcarenow.ca to learn more about VTE and how your organization can be a leader in the use of H appropriate thromboprophylaxis. ■ Hugh MacLeod is CEO of the Canadian Patient Safety Institute.

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JULY 2013 HOSPITAL NEWS


28 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

Unique collaboration creates integrated cardiac care program By Jennifer Kramer and Rebecca Slavik

A unique collaboration between Hamilton Health Sciences and Niagara Health System (NHS) has brought cardiac catheterization services to the new St. Catharines’ site of NHS. The new Heart Investigation Unit enables interventional cardiologists from Niagara and Hamilton to work together to provide quality, safe, expert cardiac care that is closer to home for Niagara residents. HHS and NHS are committed to the vision of one regional and integrated program delivered at two sites.

“Bringing this muchneeded service to Niagara will reduce the need for many patients to leave the region for care.” “We’re very proud of this collaboration,” said Dr. Madhu Natarajan, interventional cardiologist at Hamilton Health Sciences and regional physician lead for the HHSNHS integrated heart investigation unit. “Together, we’ve created an unique program that will deliver an enhanced system of cardiac care to those who need it closer to home.” In the past, all cardiac catheterization procedures were performed in the HIU at Hamilton General Hospital. Opened in 2005, the 32-bed HIU at the General is the largest centre in Ontario, with four state-ofthe-art cardiac catheterization laboratories. Twenty per cent of the patients seen at Hamilton’s cardiac catheterization program last year were Niagara residents. While many patients will now be able to

Niagara’s new Heart Investigation Unit enables interventional cardiologists from Niagara and Hamilton to work together to provide quality, safe, expert cardiac care that is closer to home for residents. receive care in Niagara, in some instances, patients with more complex needs will continue to go to Hamilton for services. The new system will include a central triage process unique in the province, providing improved continuity for patients. Physicians will also have access to online digital images, allowing for immediate consultation and faster care. “The addition of this new diagnostic service and the ongoing partnership between HHS and NHS is a great step towards providing the best cardiac care possible to the Niagara region,” said Dr. Natarajan.

“Bringing this much-needed service to Niagara will reduce the need for many patients to leave the region for care,” said Susan Kwolek, vice president, patient services, St. Catharines’ site - Niagara Health System. “We are excited about our partnership with the team at Hamilton Health Sciences, and we are so pleased to be able to offer new and enhanced cardiac care services to our community.” This model is in keeping with the Local Health Integration Network’s strategic direction of dramatically improving the patient experience by integrating service

delivery and is part of the network’s larger plan to create a regional system of care across the Hamilton, Brant, Burlington, Haldimand and Niagara communities. “I’m very proud of the work this team has done over the past two years,” said Teresa Smith, president, Hamilton General Hospital. “We’re dedicated to creating a seamless system for patients and enhancH ing our delivery of care.” ■ Jennifer Kramer is a Public Relations Specialist and Rebecca Slavik is a Communications Specialist at Niagara Health System.

Regional cardiac care enables student to live life fully Special cardiac procedure provides cure for arrhythmia patients By Bill Bath

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specialized procedure provided by Rouge Valley’s regional cardiac care team has allowed a teenage student in Whitby to have the active life she relishes. For two years, boarding school student Sallie Lau lived with a rapid heart rate. She was diagnosed with Wolff-ParkinsonWhite syndrome (WPW), a condition caused by electrical short circuits that were on the left side of her heart. These episodes can begin and end quickly. “The sensation of the episodes was like a horse running very fast inside my chest. After an episode, I would be exhausted. It was draining on my body, and would sometimes take a couple of days to recover,” says Sallie, a Grade 12 student at Trafalgar Castle girls school in Whitby. For more than a year, the regional cardiac care program at Rouge Valley Health System (RVHS) has been offering a specialized procedure to cure arrhythmias (an irregular heartbeat) like Sallie’s, which arises from the left side of the heart. The transseptal cardiac procedure takes two hours to perform, and the patient is up and HOSPITAL NEWS JULY 2013

walking within four hours and discharged from the hospital within 24 hours — sometimes even on the same day. Being able to treat WPW and other arrhythmias significantly changes patients’ lives. It eliminates repeated visits to family doctors and emergency departments where treatment is otherwise done through medication. The first transseptal procedure performed at Rouge Valley Centenary hospital campus was in February 2012. Prior to this, patients from Scarborough and Durham would have to be treated at a larger hospital specializing in more advanced cardiac care in downtown Toronto. On May 23, Sallie became the 46th patient to have the procedure done at RVHS. “Sallie had very unique circumstances. Here she was in Canada at boarding school, with her family in Hong Kong. Treating her took our expertise at this procedure, as well our commitment to open communication with her family on the other side of the world. When Sallie came for visits, my team and I would videoconference with her family to discuss her condition, explain the procedure and go over any concerns they had. The relationship we built reflects the tremendous amount

of trust Sallie’s family placed in Rouge Valley,” says Dr. Bhavanesh Makanjee, the cardiologist who performed the procedure. During her two years at the boarding school, Sallie was making regular visits to emergency departments whenever her heart rate would suddenly increase. Everyday life was physically demanding on the avid tennis player. Her schoolwork would pile up when she was recovering from an episode, and catching up and keeping up were starting to weigh on her. Even getting around the school was a chore — founded in 1874, it has no elevators and plenty of stairs. After several episodes and trips to the hospital, accompanied by the school’s registered nurse Katie Douglas, Sallie was referred to cardiologist Dr. Makanjee. As an electrophysiologist specializing in the treatment of arrhythmias, he was able to diagnose Sallie with WPW and recommend the transseptal cardiac procedure. Her mother flew to Toronto for the surgery to be there for comfort and support. “There are many benefits of this procedure. I don’t need a full day of rest anymore. I can play tennis and volleyball for the school team again. I have no spares and a full schedule of classes that I hadn’t

been able to attend. This has all changed,” says Sallie.

Rouge Valley’s regional cardiac care centre

Rouge Valley Health System has a leading cardiac care program, and is home to the regional cardiac care centre for the Scarborough-Durham area. The regional cardiac program consists of a highly-qualified and experienced team of more than 20 cardiologists and more than 100 health professionals, who serve the communities of east Toronto and Durham Region from both hospital campuses — Rouge Valley Centenary and Rouge Valley Ajax and Pickering. RVHS delivers a complete range of cardiac services, including cardiac diagnostics and consultations, as well as regional services such as life-saving cardiac catheterization and intervention procedures, arrhythmia studies and management, and cardiac rehabilitation and education. Regional services are delivered in partnership with Lakeridge Health, The Scarborough Hospital, and the Central H East Local Health Integration Network. ■ Bill Bath is a Public Affairs Intern at Rouge Valley Health System. www.hospitalnews.com


Focus 29

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES

Runnymede Healthcare Centre’s collaborative approach to managing diabetes By Sabrina Jeria t Runnymede Healthcare Centre, about 40 per cent of patients have an endocrine, metabolic or nutritional disease, such as diabetes, which can affect numerous parts of the body and lead to increased health complications—such as heart disease, stroke and kidney disease— if improperly managed or left untreated. To ensure patients live long, productive lives, Runnymede takes a proactive, interprofessional team approach to treating and managing diabetes. “Every clinical discipline—from physicians and nurses to physiotherapists and pharmacists—has an important role to play in chronic disease management at Runnymede Healthcare Centre,” says Raj Sewda, Chief Nursing Executive. “Our innovative, collaborative approach to care means that we can deliver comprehensive clinical services to an increasingly complex patient population under one roof. This ensures that our staff work to the full scope of their practice and that our patients receive the holistic care they need.” Runnymede’s team of professionals, led by physicians, deliver a multifaceted healthcare plan that addresses things such as medication, diet, exercise, foot and wound care.

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To successfully manage diabetes on a long-term basis, patients must be involved in the process.

While Type I diabetes is treated with insulin, Type II diabetes is typically treated with a combination of diet, exercise and insulin to more effectively control blood glucose levels. In addition to monitoring a patient’s blood glucose two to three times daily to ensure target levels are being met, nurses assist with managing and administering medication prescribed by the hospital’s pharmacists. The pharmacy team also monitors the effectiveness of medication on an ongoing basis to ensure diabetic patients achieve optimal blood glucose control without experiencing side effects, like hypoglycemia, commonly associated with insulin use. What, when and how much you eat plays a significant role in managing blood glucose levels for individuals with diabetes. To meet daily nutritional requirements and assist with optimal blood sugar control, the clinical dietitians at Runnymede Healthcare Centre complete a comprehensive nutritional assessment before ordering an appropriate therapeutic diet and supplements or enteral regimen based on the patient’s needs. If a patient’s sugar levels are too low or too high, his/her diet is adjusted accordwww.hospitalnews.com

ingly and monitored regularly to ensure optimal health. Regular physical activity helps the body lower and regulate blood glucose levels, making exercise a key component in the long-term management of diabetes. Many diabetic patients at Runnymede have decreased mobility though, making intense physical activity a challenge. To compensate, physio and occupational therapists prescribe a lower impact routine that promotes safety and utilizes various adaptive equipment to get patients moving. For instance, daily walking using hip protectors to prevent falls for patients with impaired balance. The therapists also recommend proper footwear, splints and/or orthotics to offload pressure from wounds or heel ulcers, common injuries in diabetic individuals. The Canadian Association of Wound Care estimates that 15 per cent of Canadians with diabetes will develop a diabetic foot ulcer in their lifetime, as the disease causes various complications that make it harder for wounds to heal. This can include neuropathy or nerve damage which reduces sensation in the hands or feet, making it harder to feel a cut or blister; clogged or narrow arteries which decrease blood flow to a wound, slowing the healing process; and/or a weakened immune system which can cause even a minor wound to become infected more easily. Runnymede’s new Inpatient Wound Care Program dedicated to the treatment of complex wounds allows patients to benefit from the expertise of a core team of wound care specialists. The team includes an experienced enterostomal therapy (ET) nurse and takes a unique approach to treating wounds that is based on applying early interventions to ensure a wound remains stable, circulation is improved and mobility is restored. The hospital’s patients also have access to an on site, independentlyoperated foot care centre with a chiropodist who focuses on treating high-risk foot conditions that result from diabetes, such as ulcers, corns and calluses. To successfully manage diabetes on a long-term basis, patients must be involved in the process. As a result, the hospital’s clinical staff provides diabetes education to patients and their families. Nursing and pharmacy staff work together to teach patients how to monitor their blood glucose levels and administer insulin injections. Dietitians provide tips on healthy eating and weight management. Occupational therapists discuss ways to prevent falls during daily activities. The physiotherapy and wound care teams instruct patients on proper foot inspection, including how to check for cuts and/or bruising, and preventing foot lesions by thoroughly drying feet after bathing and regularly moisturizing skin to prevent cracks that may cause infections. By providing ongoing support that focuses on managing chronic diseases and promoting wellness to prevent further illness or injury, Runnymede Healthcare Centre greatly improves the quality of life H of patients every day. ■ Sabrina Jeria is a Communications Associate at Runnymede Healthcare Centre.

Ultraviolet C light treatment is used at Runnymede Healthcare Centre to treat patients with complex wounds, such as diabetic foot ulcers.

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JULY 2013 HOSPITAL NEWS


30 Ethics

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

We try to list all events and information but due to space constraints and demand, we cannot guarantee it. To promote your event in a larger, customized format please send enquiries to “advertising@hospitalnews.com” ■ July 7-10, 2013 International Tumor Necrosis Factor Conference Quebec City, Quebec Website: www.tnf2013.com ■ July 9-11, 2013 Biennial Conference on Brain Injury in Children Park Hyatt Hotel, Toronto Website: www.sickkids.ca/BrainNetwork ■ July 10-14,2013 World Congress on Thyroid Cancer Sheraton Centre Toronto Hotel, Toronto Website: thyroidworldcongress.com ■ July 17-20, 2013 World Glaucoma Congress New Vancouver Convention Centre, Vancouver Website: www.worldglaucoma.org ■ July 24-28, 2013 Brain Development & Learning: Making Sense of the Science The Westin Bayshore, Vancouver Website: www.braindevelopmentandlearning.com ■ July 26-29, 2013 International Academy of Cardiology – 18th World Congress on Heart Disease Hyatt Regency, Vancouver Website: cardiologyonline.com ■ Sept 8-10, 2013 CSAO Conference – Canadian MDRD Processes Double Tree Hilton, Toronto Website: www.csao.net ■ Sept 13-14, 2013 Canadian Association of Ambulatory Care Conference Delta Toronto East, Toronto Website: www.canadianambulatorycare.com ■ Sept 22nd-24th, 2013 Dynsmics 2013 Conference – Shattering the Silence – Voices for Advocacy in Critical Care Nursing World Trade & Convention Centre, Nova Scotia Website: www.caccn.ca ■ Sept. 24-25, 2013 National Forum on Patient Experience The Westin Bristol Place, Toronto Airport Website:www.patientexperiencesummit.com ■ Sept 25-27, 2013 Brain Injury Association of Canada Conference Ambassador Conference Resort, Kingston Website: www.biac-aclc.ca ■ Oct 3-4, 2013 I.T. Healthcare Canada Conference and Exhibition International Centre, Toronto Website: www.ithealthcare.ca ■ Oct 18-22, 2013 International Association for Child & Adolescent Psychiatry and Allied Professions World Congress Calgary Telus Convention Centre, Calgary Website: www.iacapap2016.org ■ Nov 4-6th, 2013 Health Achieve 2013 Metro Toronto Convention Centre, Toronto Website: www.healthachieve.com To see even more Healthcare Industry Events, please visit our website www.hospitalnews.com/events HOSPITAL NEWS JULY 2013

Don’t ignore those ethics red flags By Jonathan Breslin, PhD

couple of weeks ago I participated in two case reviews for a community care organization, one of which dealt with issues that were identified at the point of transfer from hospital to the community. One of the cases unfortunately had a very tragic outcome for a patient; the other could have ended tragically too, if not for one very astute staff member who identified some significant and unaddressed issues with the consent process. The learning opportunities in these cases from an ethics point of view related to the fact that participants in both reviews spoke about the red flags that weren’t given proper consideration.

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It is important to always remember that your primary ethical responsibility is to the patient.

What do I mean by ethics red flags? They refer to anything that pops up in the care of a patient that makes you pause – that sometimes fleeting intuitive reaction that something isn’t quite right. That’s the first and often the most reliable sign of an ethical issue, or at least a potential ethical issue. It may manifest as a feeling of discomfort about something in the patient’s care – something that doesn’t sit right with you. Sometimes you are able to articulate exactly what the issue is but perhaps you’re not sure how serious it is, or you’re afraid

to bring it up, or maybe you second-guess your own intuition if nobody else on the team is concerned. One area where ethics red flags are very common is the consent process, as happened in one of the cases I helped review. There are a number of places throughout the consent process where the basic standards of consent can be and often are overlooked in a busy health care environment. For example, it is common for family members of a patient to be given decision making authority without first asking the patient whether he or she wants it this way or without determining whether the patient is capable of making his or her own decision. Another common example is the use of family members as translators, which can interfere with our ability to transmit accurate information back and forth with the patient. A third example involves assuming that the person who has accompanied the patient, or who visits the patient most often, is the appropriate substitute decision maker. When these or other ethics red flags pop up in your work, please don’t ignore them. It is important to always remember that your primary ethical responsibility is to the patient, and fulfilling that responsibility means always paying attention to red flags when they arise. When they do arise that is the time to slow down, reflect on what is happening, and consult with people who can support you in your decision making (such as colleagues, your supervisor, or an ethicist). While it is always easier to give people benefit of the doubt, and the red flags can often be brushed aside without serious consequences, one preventable H tragic outcome is too many. ■ Jonathan Breslin is an independent ethics consultant and educator and an Assistant Professor in the Institute of Health Policy, Management and Evaluation at The University of Toronto.

Stroke care

Continued from page 20 The goal is to ensure that essential conversations occur during clinical handover so healthcare professionals at all levels understand what has taken place in order to improve transitions and better meet the needs of persons with stroke and their caregivers.

3) Peers Fostering Hope:

A volunteer program that links stroke patients and their caregivers with peer supporters who have experienced a stroke. Through a partnership between the Toronto Stroke Networks and the JULY of Dimes Canada, peers connect with and offer timely support and linkages to persons and caregivers living with stroke, in either acute care or rehabilitation, in an effort to transform the image of stroke to one of hope and possibility. This one-to-one peer support provides hope, reassurance, and first-hand knowledge of what it is like to experience and live with a stroke. The process is felt to be reciprocal in that the peers gain selfconfidence, reinforcement of coping strategies and personal sense of worth and satisfaction. The value of peer sup-

port groups has been shown to have many positive outcomes. Evaluation of these projects is set to be completed by JULY 2014 and the results are expected to provide a better understanding of the value and benefits of these programs in order to inform ongoing implementation. “The anectodal feedback so far has been very positive, suggesting the benefits of the programs are greater than what was anticipated,” adds Linkewich. “There has been a culture shift towards more collaboration between sites, giving a strong survivor voice and more hopeful H optimistic care.” ■ Dr. Sylvia Quant, is a Rehab & Community Re-engagement Coordinator for the North & East GTA Stroke Network, and a Lecturer with the Department of Physical Therapy, Faculty of Medicine, University of Toronto. Sharron Runions is a Clinical Nurse Specialist in the North & East GTA Stroke Network. Sybil Edmonds and Nadia Norcia Radovini are both Communications Advisors at Sunnybrook Health Sciences Centre. www.hospitalnews.com


The Doctor Game 31

Appendicitis: It nearly killed King Edward VII By W. Gifford-Jones ow would you like to be the young surgeon in 1902 who was asked to see Prince Edward who was to be crowned King of England in two days? His Mother, Queen Victoria, had reigned so long that Edward had become the playboy prince. Now he was obese, old, flatulent and a terrible operative risk. Young Dr. Treves diagnosed a ruptured appendix and recommended surgery, much to the consternation of other doctors. While Treves operated, officials were preparing for the king’s funeral. But Treves got lucky. His decision proved prudent. He simply drained an abscess and left the appendix alone. No doubt Treves also lifted more than one prayer to the Almighty. Luckily, Edward survived and was later crowned King Edward VII of England. Treves was knighted for his efforts. A report from the Canadian Medical Protective Association shows that it’s not only kings that develop a ruptured appendix. Some form an abscess and kill patients. Others do not. This year about 250,000 appendectomies will be done in North America. Fortunately, it’s rare today to die from uncomplicated appendicitis. But when trouble

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strikes, the cause is usually a delay in diagnosis and treatment. A typical attack of appendicitis starts with abdominal pain. But contrary to what most people think, it doesn’t begin in the right side. Rather, it starts in the upper part of the abdomen. Sometimes it’s only a nagging discomfort. But at other times it can be associated with severe pain along with nausea and vomiting.

Today more cases of appendicitis are being diagnosed by either CT scans or ultrasound. After several hours the pain finally gravitates to the lower right side. This soreness is apt to be increased by coughing or any other jolt. Normally, there is also a slight elevation of temperature. The great problem is that this textbook description of appendicitis doesn’t always happen. The Canadian Medical Protective Association report outlines common problems that can trigger complications. For example, one patient complained of abdominal pain lasting two days, along with nausea and vomiting. But the doctor believed the

Careers

abdominal discomfort was related to sore muscles due to strain of vomiting. She was discharged with a diagnosis of gastroenteritis. But then in this case, and frequently in others, a big mistake occurred. The patient was not provided with adequate information of what to do if symptoms failed to subside. Several days later the patient’s condition deteriorated and she was seen in the emergency department. This time the diagnosis was a ruptured appendix with abscess. But now the patient also required removal of part of the large and small bowel. What could have been a simple appendectomy had turned into a major procedure. In another case, a grossly overweight patient with vague abdominal complaints was sent home and advised to return if fever, vomiting or the pain became worse. A few days later a CT scan diagnosed appendicitis and surgery was performed with a happy outcome. But obesity always makes the diagnosis more difficult and complications more likely. But not in this case. Today more cases of appendicitis are being diagnosed by either CT scans or ultrasound. In addition, some appendectomies are being performed by laparoscopy, resulting in a shortened post-operative recovery. Can the King Edward disease be prevented? Appendicitis is virtually unknown in Ke-

nya, Uganda, Egypt and India where people eat a high fiber diet. And during the second world war, when the Swiss were forced to consume less refined sugar and more fiber, their rate of appendicitis dropped. It’s interesting how the surgical treatment of appendectomy has changed over the years. The great French surgeon, Dupuytren, ridiculed the notion that it was impossible for such a small organ to produce such disastrous results. Others disagreed with him. In 1855 one surgeon, Henry Sands of New York, merely stitched up the perforated hole in an appendix. He then returned the appendix to the abdomen and the patient survived. More due to the grace of the Almighty than sound surgical judgment, it seems. Remember, if you have abdominal pain don’t delay in seeking attention. Never, never take a laxative to ease the pain and don’t eat or drink. Both can cause trouble if surgery is needed. See the web site www.docgiff.com For H comments info@docgiff.com. ■ The Doctor Game is a syndicated column that appears in over 40 newspapers in Canada. W. Gifford-Jones is a pseudonym for Dr. Ken Walker, a gynecologist at First Canada Place.

DEADLINE FOR AUGUST 2013 ISSUE: JULY 26, 2013

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ƚs,,ŽŵĞ,ĞĂůƚŚĂƌĞ͕more is not just ŽƵƌĐŽŵŵŝƚŵĞŶƚƚŽŽƵƌĐůŝĞŶƚƐ͕ďƵƚƚŽŽƵƌ ŝŶĐƌĞĚŝďůĞƚĞĂŵŽĨŚĞĂůƚŚĐĂƌĞǁŽƌŬĞƌƐ͘ Get more out of your career with: ͻ ZĞĂůƌĞƐƵůƚƐŝŶƚŚĞƌĞĂůǁŽƌůĚ͘zŽƵ͛ůůĨŽƐƚĞƌŽŶĞͲŽŶͲŽŶĞƌĞůĂƟŽŶƐŚŝƉƐ  ǁŝƚŚĐůŝĞŶƚƐƚŽŚĞůƉƚŚĞŵĂĐŚŝĞǀĞmore control in their care and more independenceŽǀĞƌƚŚĞŝƌůŝǀĞƐ͘ ͻ ŶŽƌŐĂŶŝnjĂƟŽŶĂůĐƵůƚƵƌĞƚŚĂƚĚƌŝǀĞƐmore outstanding home care  ƚŚƌŽƵŐŚƉƌĞĐĞƉƚŽƌƚƌĂŝŶŝŶŐ͕ŵĞŶƚŽƌƐŚŝƉƉƌŽŐƌĂŵƐ͕ϮϰͬϳŽŶͲĐĂůů  ŶƵƌƐŝŶŐƐƵƉƉŽƌƚĂŶĚŵŽŶƚŚůLJƚĞĂŵŵĞĞƟŶŐƐƚŽĐŽŶŶĞĐƚǁŝƚŚĐŽůůĞĂŐƵĞƐ ͻũŽďƚŚĂƚŝŶƐƉŝƌĞƐLJŽƵƚŽƵŶĐŽǀĞƌmore talent ĂŶĚŝŶŶŽǀĂƟŽŶ͘zŽƵ͛ůůďĞďĂĐŬĞĚďLJĂƐƵƉƉŽƌƟǀĞ ůĞĂĚĞƌƐŚŝƉƚĞĂŵƚŚĂƚŶŽƚŽŶůLJĞŶĐŽƵƌĂŐĞƐLJŽƵƚŽ ĐƌĞĂƟǀĞůLJƉƌŽďůĞŵͲƐŽůǀĞ͕ďƵƚĞŵƉŽǁĞƌƐLJŽƵƚŽ ĚĞůŝǀĞƌƐƉĞĐƚĂĐƵůĂƌĐĂƌĞ͘ tĞĂƌĞĐƵƌƌĞŶƚůLJƐĞĞŬŝŶŐ;ĨƵůůͲƟŵĞΘƉĂƌƚͲƟŵĞͿ͗ ͻZĞŐŝƐƚĞƌĞĚEƵƌƐĞƐ;ZEƐͿ ͻZĞŐŝƐƚĞƌĞĚWƌĂĐƟĐĂůEƵƌƐĞƐ;ZWEƐͿ ͻWŚLJƐŝŽƚŚĞƌĂƉŝƐƚƐ;WdƐͿ ͻKĐĐƵƉĂƟŽŶĂůdŚĞƌĂƉŝƐƚƐ;KdƐͿ VHA Home HealthCare is an Equal Opportunity Employer ĐĐƌĞĚŝƚĞĚďLJĐĐƌĞĚŝƚĂƟŽŶĂŶĂĚĂ

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WůĞĂƐĞĂƉƉůLJŽŶůŝŶĞĂƚǁǁǁ͘ǀŚĂ͘ĐĂ JULY 2013 HOSPITAL NEWS


32 Focus

CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES BIOMED PRESENTS...

BETTER SLEEP/BETTER MEMORY A Seminar for Health Professionals TUITION $109.00 (CANADIAN)

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The seminar registration period is from 7:45 AM to 8:15 AM. The seminar will begin at 8:30 AM. A lunch (on own) break will take place from 11:30 AM to 12:20 PM. The course will adjourn at 3:30 PM, when course compleWLRQFHUWLÂżFDWHVZLOOEHGLVWULEXWHG Registration: 7:45 AM â&#x20AC;&#x201C; 8:30 AM Morning Lecture: 8:30 AM â&#x20AC;&#x201C; 10:00 AM z Sleep: Why Do We Sleep? Do We Need To Sleep? z Biorhythms: Sleep Patterns and Disruptions. z Shift Work: $0DMRU5LVNIRU&DUGLRYDVFXODU'LVHDVHDQG'LDEHWHV"'R/RQJHU6KLIWV0HDQ0RUH0LVWDNHV"-HW/DJ&DXVHVDQG5HFRYHU\ z How We Sleep At Night: Sleep Stages and Sleep Architecture. NREM (Non-Rapid Eye Movement) to REM (Rapid Eye Movement). z Dreaming And Memory: The Powerful Sleep-Memory Connection. z Lucid Dreams: %HLQJ$ZDUHRI6OHHS&DQ3DWLHQWV/HDUQWR,QĂ&#x20AC;XHQFHWKH&RQWHQWRI7KHLU'UHDPV z To Nap or Not To Nap? Do Nappers Have Better Cognition, Better Memory? Mid-Morning Lecture: 10:00 AM â&#x20AC;&#x201C; 11:30 AM z Caffeine, Alcohol, and Sleep: Whatâ&#x20AC;&#x2122;s the Real Story? z Sleep Deprivation, Insomnia, and The Heart: A Scary Connection. z Too Much Or Too Little Sleep. Are Both Detrimental To Your Health? z The Dangerous Links among Sleep Disruption, Obesity, and Diabetes. z Diagnosing Sleep Disorders: Sleep Specialists and Sleep Diaries. z Sleep Disorders: Insomnia, Sleep Apnea, Restless Legs, and Periodic Limb Movement Disorder. z Sleep Apnea Treatment: Oral Appliances, Surgery, CPAP, BiPAP, or Medications? Do They Improve Cardiovascular Health? Does Diet Help? Lunch: 11:30 AM â&#x20AC;&#x201C; 12:20 PM Afternoon Lecture: 12:20 PM â&#x20AC;&#x201C; 2:00 PM z Orofacial Pain and Sleep Disruption. The Mouth Pain/Insomnia Connection. z Types Of Sleep Medications: Do They Work? Which Are Best? How Long Should You Take Them? Is Melatonin Helpful For Anything? z Sleep Hygiene: Simple Lifestyle Changes That Can Improve Sleep. z Stages And Types Of Human Memory. Acquisition Vs. Retrieval. Short-Term Vs. Long-Term. Declarative Vs. Procedural. z Retrieval of Memories: How Accurate Is Our Recall of Events? September 11. z â&#x20AC;&#x153;Flashbulbâ&#x20AC;? Emotional Memories: Are Some Memories with Us Forever? z Sleep And Memory. Dream Sleep and Memory Consolidation. z High Blood Pressure and Memory. Mid-Afternoon Lecture: 2:00 PM â&#x20AC;&#x201C; 3:20 PM z Eating and Memory. Can Better Nutrition Prevent Memory Loss? z Why a Picture Is Worth A Thousand Words Regarding Memory. z Overtime At Work. Long Work Hours and Decreased Memory Function. z Stress And Memory. The â&#x20AC;&#x153;Inverted Uâ&#x20AC;? Curve. z Aging And Memory. How Learning And Remembering Change Over Time. z The â&#x20AC;&#x153;45â&#x20AC;? Rule: Do Cognitive Functions Begin to Decline at Age 45? z Nutrition and Memory Loss. Depression And Dementia. Which Comes First? Evaluation, Questions, and Answers: 3:20 PM â&#x20AC;&#x201C; 3:30 PM

6 CONTACT HOURS / www.biomedglobal.com

MEETING TIMES & LOCATIONS

OTTAWA, ON

TORONTO, ON

Thu., Nov. 7, 2013 8:30 AM to 3:30 PM Hilton Garden Inn Ottawa Airport 2400 Alert Rd. Ottawa, ON TUITION:

LONDON, ON

Fri., Nov. 8, 2013 8:30 AM to 3:30 PM Holiday Inn Toronto Yorkdale 3450 Dufferin St. Toronto-Yorkdale, ON

TORONTO, ON

Wed., Nov. 13, 2013 8:30 AM to 3:30 PM Hilton London Ontario 300 King St. London, ON

Thu., Nov. 14, 2013 8:30 AM to 3:30 PM 'D\V+RWHO &RQIHUHQFH&HQWHU 185 Yorkland Blvd. Toronto, ON

CHEQUES: $109.00 (CANADIAN) with pre-registration. $134.00 (CANADIAN) at the door if space remains. CREDIT CARDS: Charges by credit card will be processed in U.S. DOLLARS at the prevailing exchange rate. Note: some Canadian banks may add a small service charge for using a credit card. The tuition includes all applicable Canadian taxes. At the seminar, participants will receive a complete course syllabus. Tuition payment receipt will also be available at the seminar.

ACCREDITATION

7KLVSURJUDPLVGHVLJQHGWRSURYLGHQXUVHVZLWKWKHODWHVWVFLHQWLÂżFDQG clinical information and to upgrade their professional skills. Numerous registered nurses in Canada and the United States have completed these courses. This activity is co-provided with INR. Biomed is an approved provider of continuing nursing education by the Arizona Nurses Association, an accredited approver by the American Nurses Credentialing Centerâ&#x20AC;&#x2122;s Commission on Accreditation.

PHARMACISTS

Pharmacists successfully completing this course will receive course FRPSOHWLRQFHUWLÂżFDWHV%LRPHGLVDFFUHGLWHGE\WKH$FFUHGLWDWLRQ&RXQFLO for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. The ACPE universal activity number (UAN) for this course is 02129999-13-002-L01-P. This is a knowledge-based CPE activity.

DIETITIANS

CPE

Biomed, under Provider Number BI001, is a Continuing Profes- Accredited Provider sional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDâ&#x20AC;&#x2122;s) and dietetic technicians, registered (DTRâ&#x20AC;&#x2122;s) will receive 6 hours worth of continuing professional education units (CPEUâ&#x20AC;&#x2122;s) for completion of this program/materials. Continuing Professional Education Provider Accreditation does not constitute endorsement by CDR of a provider, program, or materials. CDR is the credentialing agency for the Academy of Nutrition and Dietetics.

PSYCHOLOGISTS &RXUVHFRPSOHWLRQFHUWLÂżFDWHVZLOOEHGLVWULEXWHGWRSV\FKRORJLVWVFRPSOHWing this program. This activity is co-provided with INR. INR is approved by the American Psychological Association to sponsor continuing education for psychologists. INR maintains responsibility for this program and its content.

SOCIAL WORKERS

Social Workers completing this program will receive course completion FHUWLÂżFDWHV

Dr. Michael E. Howard (Ph.D.) is a full-time psychologist-lecturer for INR. 'U +RZDUG LV D ERDUGFHUWLÂżHG FOLQLFDO QHXURSV\FKRORJLVW DQG KHDOWK SV\FKRORgist who is an internationally-recognized authority on brain-behavior relationships, traumatic brain injury, dementia, stroke, psychiatric disorders, aging, forensic neuropsychology, and rehabilitation. Dr. R.S. Hullon (M.D., J.D.) is a full-time physician-lecturer for INR. Dr. Hullon is a physician and surgeon specializing in trauma and orthopedics. His medical experience includes diagnosis and treatment of infectious diseases, neurological disorders, neurodegenerative diseases (multiple sclerosis, Parkinsonâ&#x20AC;&#x2122;s, and Alzheimerâ&#x20AC;&#x2122;s diseases) and psychiatric disorders (personality and mood disorders). Biomed reserves the right to change instructors without prior notice. Every instructor is either a compensated employee or independent contractor of Biomed.

LEARNING OBJECTIVES 1) 2) 3) 4) 5) 6) 7)

Participants completing this course will be able to: describe the stages, cycling, and rhythms of sleep. distinguish between healthy and unhealthy sleep patterns. cite evidence connecting sleep deprivation and sleep disorders to heart disease, stroke, diabetes, and dementia. describe the connection between dental pain and sleep disruption. discuss the relationship between sleep stages and the formation of new memories. cite the various affects of aging, stress, hypertension, diet, medications, supplements, and dementias on memory processing. describe for this course, the implications for dentistry, mental health, nursing, and other health care professions.

SPONSOR %LRPHGLVDVFLHQWLÂżFRUJDQL]DWLRQGHGLFDWHGWRUHVHDUFKDQGHGXFDWLRQLQVFLHQFH and medicine. Since 1994, Biomed has been giving educational seminars to Canadian health-care professionals. Biomed neither solicits nor receives gifts or grants from any HQWLW\6SHFLÂżFDOO\%LRPHGWDNHVQRIXQGVIURPSKDUPDFHXWLFDOIRRGRULQVXUDQFH companies. Biomed has no ties to any commercial organizations and sells no products of any kind, except educational materials. Neither Biomed nor any Biomed instructor has a PDWHULDORURWKHUÂżQDQFLDOUHODWLRQVKLSZLWKDQ\KHDOWKFDUHUHODWHGEXVLQHVVRUDQ\ other entity which has products or services that may be discussed in the program. Biomed does not solicit or receive any gifts from any source and has no connection with any religious or political entities. Biomedâ&#x20AC;&#x2122;s telephone number is: (925) 602-6140. Biomedâ&#x20AC;&#x2122;s fax number is: (925) 363-7798. Biomedâ&#x20AC;&#x2122;s corporate headquartersâ&#x20AC;&#x2122; address is: Biomed, P.O. Box 5727, Concord, CA 94524-0727, USA. Biomedâ&#x20AC;&#x2122;s GST Number is: 89506 2842.

1-888-724-6633.

(This number is for registrations only.) Fax a copy of your completed registration formâ&#x20AC;&#x201D; including Visa, MasterCard, American ExpressÂŽ, or DiscoverÂŽ Numberâ&#x20AC;&#x201D;to (925) 687-0860.

By fax:

For information about seminars in other provinces, please call 1-877-246-6336 or (925) 602-6140.

REGISTRATION INFORMATION Individuals registering by Visa, MasterCard, American ExpressÂŽ, or DiscoverÂŽ will be charged at the prevailing exchange rate. If the credit card account is with a Canadian bank, the USA tuition will be converted into the equivalent amount in Canadian dollars (approximately $109.00) and will appear on the customerâ&#x20AC;&#x2122;s bill as such. The rate of exchange used will be the one prevailing at the time of the transaction. Please register early and arrive before the scheduled start time. Space is limited. Attendees requiring special accommodation must advise Biomed in writing at least 50 days in advance and provide proof of disability. Registrations are subject to cancellation after the scheduled start time. A transfer at no cost can be made from one seminar location to another if space is available. Registrants cancelling up to 72 hours before a seminar will receive a tuition refund less a $35.00 (CANADIAN) administrative fee or, if requested, a full-value voucher, good for one year, for a future seminar. Other cancellation requests will only be honored with a voucher. Cancellation or voucher requests must be made in writing. If a seminar cannot be held for reasons beyond the control of the sponsor (e.g., acts of God), the registrant will receive free admission to a rescheduled seminar or a full-value voucher, good for one year, for a future seminar. A $35.00 (CANADIAN) service charge applies to each returned cheque. Nonpayment of full tuition may, at the sponsorâ&#x20AC;&#x2122;s option, result in cancellation of CE credits issued. The tuition includes all applicable Canadian taxes. At the seminar, course participants will receive a complete syllabus. Tuition payment receipt will also be available at the seminar. A $15.00 fee will be charged for the issuance of a GXSOLFDWHFHUWLÂżFDWH)HHVVXEMHFWWRFKDQJHZLWKRXWQRWLFH

(enter all raised numbers)

Wed., Nov. 13, 2013 (London, ON) Thu., Nov. 14, 2013 (Toronto, ON)

E-Mail:

For information about seminars in other provinces, please call 1-877-246-6336 or (925) 602-6140



Thu., Nov. 7, 2013 (Ottawa, ON) Fri., Nov. 8, 2013 (Toronto-Yorkdale, ON)

Charges by credit card will be processed in U.S. dollars. The prevailing rate of exchange will be used.

Signature:

ExpressÂŽ, or DiscoverÂŽ by calling

REGISTRATION FORM

Please print: Name: Home Address: City: Province: Postal Code: Home Phone: ( ) Work Phone: ( ) Please enclose full payment with registration form. Check method of payment. Check for $109.00 (CANADIAN) (Make payable to BIOMED) Charge the equivalent of $109.00 (CANADIAN) to my Visa Card Number:

There are four ways to register: Online: www.biomedglobal.com By mail: Complete and return the Registration Form below. By phone: Register toll-free with Visa, MasterCard, American

Profession: Professional License #: Lic. Exp. Date: Employer: QHHGHGIRUFRQÂżUPDWLRQ UHFHLSW

MasterCard

American ExpressÂŽ

Exp. Date:

DiscoverÂŽ



Please check course date:

HOW TO REGISTER

INSTRUCTORS

REGISTERED NURSES (RNs) & LICENSED PRACTICAL NURSES (LPNs)

Please return form to:

BIOMED

Suite 228 3219 Yonge Street Toronto, Ontario M4N 2L3 TOLL-FREE: 1-877-246-6336 TEL: (925) 602-6140 FAX: (925) 687-0860

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HOSPITAL NEWS JULY 2013

www.hospitalnews.com

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