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Inside: From the CEO’s Desk / Evidence Matters / Trends in Transformation / HN Podium

July 2017 Edition

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NEWS

What should we be paying for in our publicly funded health system? By Raisa Deber

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s a recent Globe and Mail investigation has noted, some Canadians have had to pay extra for care that they thought would be fully covered. The investigation reveals how complex this set of issues can be. As many do not realize, Canada’s healthcare system is not “public.” Unlike public school teachers, those providing healthcare are not government employees. What we call “public hospitals” are actually private, not-for-profit organizations. Canada’s system is what the OECD calls a “public contracting” model, which relies on public financing of private providers. Neither is there a Canadian system. Because healthcare in Canada is deemed to be under provincial jurisdiction, there is considerable variation across the country.

ONLY ABOUT 70 PER CENT OF HEALTHCARE IS PUBLICLY FINANCED

However, to receive federal money, provincial insurance plans are required to fully fund all “insured services” to “insured persons.” For historical reasons, the definition of what qualifies as insured services is based both on being “medically necessary” and on who provides them (physicians) and where (in hospitals). As a result, only about 70 per cent of healthcare is publicly financed. Private payment finances most dental care and a considerable proportion of rehabilitation, outpatient pharmaceuticals and long-term care. As care moves outside of hospitals, there is ac-

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cordingly, increased scope for it moving outside this public funding model. One implication of our current model is that, to the extent that services being provided in private clinics do not fall under the “medically necessary” definition, there is nothing illegal about additional charges. Cosmetic surgery or “executive health assessments” are obvious examples. But as the investigative reporting noted, certain doctors have also found loopholes, where they can charge for additional services that fall outside the definition of insured services. One striking example was from an Ontario patient being asked to pay $495 to see a dietitian, which would not qualify as an insured service, in order to be placed higher on the list for a publicly funded colonoscopy. Other examples illustrate additional perfectly legal loopholes, including those relating to the treatment of work-related injuries that are (legally) paid for by workers’ compensation boards. There are also differences in what the provincial funding bodies have decided are deemed to be insured services. For example, Ontario regulates what they term “independent health facilities,” which offer services that might otherwise be performed in hospitals, and prohibits them from charging “facility fees” to patients for services that would be publicly insured. Many other provinces do not, which allows providers to legally “double dip” since they are charging for additional services that are not necessarily publicly insured. The investigation made a strong case for clamping down on these activities, although one could dispute the extent

to which they are actually illegal as opposed to being ethically problematic. The international evidence strongly suggests that there are few benefits to allowing private payment. This is logical – there is no reason to pay extra for services that would be publicly covered unless what you could get for “free” is inferior or seen to be. Since there is no reason to pay to bypass a queue unless that queue is long, the evidence has found that allowing private payment does indeed make the publicly available care worse. More promising approaches to improving wait times include both making sure the necessary resources are in place, and learning from engineers and improving queue management, including encouraging single points of entry. A better question, in my view, is asking what we should be paying for. And, if we are going to invest more money, place it where we can improve peoples’ health. This may indeed mean that, rather than insisting people be treated in hospitals in order to receive necessary pharmaceuticals or rehabilitation, we extend the list of insured services to cover medically necessary care, regardless of where it is delivered or by who. We must also recognize that more is not always better. Receiving a diagnostic test that isn’t needed, and the unnecessary radiation that may go with it, is not always a good thing. How many people without cancer should receive therapy that may damage them to avoid missing one case? We shouldn’t be frightening people with the sense that not paying for more care – care they may not need and that may harm them – means that they may die. Instead we should be backing clinicians, including those at Choosing Wisely Canada, who are searching for the win-win of improved outcomes at H lower costs. ■

Raisa Deber is a Professor at the Institute of Health Policy, Management and Evaluation, University of Toronto and an expert advisor with EvidenceNetwork.ca. Her newest book, Treating Healthcare will be released by University of Toronto Press in December, 2017. 2 HOSPITAL NEWS JULY 2017

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Contents July 2017 Edition

IN THIS ISSUE:

Providing quality cardiac care to growing population

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▲ Cover story: Hypertension in children

18

▲ Patient has his mechanical heart removed

12

This Issue

What should we pay for? .................2 Guest editorial .................................4 In brief ..............................................6 Advancing cardiovascular care .........................8 Trends in transformation .............................. 10 Evidence matters .......................... 16 From the CEO’s desk .................... 20 Reducing need for open heart surgery ....................... 22 Using Canadian invented device in novel way ...................... 24 Can hockey save healthcare system? ...................... 24 Lean approach to reduce surgical wait times ....................... 26 Patient centred diabetes care ..... 28 Doctors without Borders .............. 29 HN Podium .................................... 30 www.hospitalnews.com

▲ A dance study for people with COPD

11

▲ Canadian first: Implant of novel sensor device

14

Motivating patients to get fit

5

▲ Lower gestational diabetes rates in cold temperatures

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Monthly Focus: Paediatrics/Ambulatory Care/Neurology/ Hospital-based Social Work: Pediatric programs and developments in the treatment of paediatric disorders including autism. Specialized programs offered on an outpatient basis. Developments in the treatment of neurodegenerative disorders (Alzheimer’s, Parkinson’s etc.), traumatic brain injury and tumours. Social work programs helping patients and families address the impact of illness.

Monthly Focus: Emergency Services/Critical Care/Trauma/ Emergency Preparedness/Infection Control: Innovations in emergency and trauma delivery systems. Emergency preparedness issues facing hospitals and how they are addressing them Advances in critical care medicine. Programs implemented to reduce hospital acquired infections. Developments in the prevention and treatment of drug-resistant bacteria and control of infectious diseases.

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until his family secured him a spot he care we provide imin a costly and unnecessary nursing pacts the lives of our home to wait for the appropriate patients and their familong-term care bed. lies. It can also increase This experience – and too many life expectancy, which stand today others like it – demonstrates the at 81 years, almost a full decade gap between the needs of aging higher than it was fifty years ago. Canadians and what our system Indeed, so many Canadians are livcan provide. As a result, the Canaing longer today and our nation has dian Medical Association (CMA) more people aged 65 and over than launched its Demand a Plan camthere are under 15. If we are going paign to encourage government, to build on that success story we providers and Canadians to rethink must first build a health care system how our system should operate to that supports the best health in our support healthy aging. We have deolder years. Dr. Granger Avery veloped recommendations based on We know all too well how overextensive review of health outcomes, system and ecoreliance on hospitals has stretched resources thin and nomic performance and real stories from Canadian. is driving wait times up Emergency departments are Our priority recommendation calls for capital instretched to their limits, and hospital beds are too ofvestments to create more residential care beds in ten occupied by patients who would benefit from a long-term care homes, assisted living units and other different care setting. But with few alternatives, what innovative residential models. Additionally, we recare Canadians to do? ommend investments to retrofit and renovate existing A patient’s daughter was faced with such a conflict. facilities. This will allow people to get the help they Her father was hospitalized after a fall broke his hip. need in the most appropriate manner, creating effiWhile in hospital, he broke his other hip. Without ciencies in the system and freeing up overburdened appropriate supports in place at home or an available hospital resources to focus on the most complex cases. long-term care bed, his hospital stay was extended Continued on page 7

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Hospital News is published for hospital health-care professionals, patients, visitors and students. It is available free of charge from distribution racks in hospitals in Ontario. Bulk subscriptions are available for hospitals outside Ontario. The statements, opinions and viewpoints made or expressed by the writers do not necessarily represent the opinions and views of Hospital News, or the publishers. Hospital News and Members of the Advisory Board assume no responsibility or liability for claims, statements, opinions or views, written or reported by its contributing writers, including product or service information that is advertised. Changes of address, notices, subscriptions orders and undeliverable address notifications. Subscription rate in Canada for single copies is $29.40 per year. Send enquiries to: subscriptions@ hospitalnews.com Canadian Publications mail sales product agreement number 42578518.

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FOCUS

How do you

motivate and inspire patients to get fit? By Barb Gormley egular physical activity is an important part of good diabetes management, but sometimes it is hard for people to incorporate into their daily routines. That’s where healthcare professionals can help. Here are tips and advice from three diabetes education centres, which are part of the Diabetes Education Standards Recognition Program of Diabetes Canada’s Diabetes Educator (or Professional) Section.

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Adult Diabetes Centres at Trillium Health Partners

(Credit Valley Hospital and the Mississauga Hospital, Mississauga, Ont.) This is the largest outpatient diabetes program in the country. The team currently works with more than 12,000 adults who have diabetes, prediabetes, or gestational diabetes. “Our new patients often tell us they had no idea that regular exercise, even three 10-minute bouts of walking per day, could have such a huge impact on their blood sugar levels and make them feel so much healthier and energetic,” says Stacey Horodezny, who manages the diabetes programs. Tip #1: “We recommend patients check their blood sugar before and immediately after physical activity to see for themselves what a difference activity can make,” says Horodezny. “We find that this motivates people to do even more activity, which helps to further reduce their blood sugar and support any weight loss goals they may have.” Tip #2: “Whenever possible, we also encourage patients to get their family and friends moving with them, to make physical activity and healthy living more fun and to help them stick with it,” says Horodezny. www.hospitalnews.com

Grand Bend Area Community Health Centre

(Grand Bend, Ont.) The centre offers programs for people of all ages and abilities, from seniors to young active individuals, and it strongly emphasizes the many health benefits of physical activity for people with type 1 or type 2 diabetes. “People are pleasantly surprised when they begin exercising with us because we help them choose an activity that they find enjoyable – such as walking, chair exercises, or one of our many fitness classes – and goals that are realistic for them,” says Patricia Baker, a registered dietitian and certified diabetes educator. Tip #1: If people get off track, we suggest brainstorming strategies with their diabetes professional right away, says JoAnne Aitken, a registered nurse and certified diabetes educator at the centre. Tip #2: It’s important to celebrate your clients’ successes along the way, says Aitken. “For example, some of our clients who lose weight reward themselves with new clothes, and as educators we always verbally recognize their hard work in achieving their goals.”

REGULAR PHYSICAL ACTIVITY IS AN IMPORTANT PART OF GOOD DIABETES MANAGEMENT and a counsellor who incorporate exercise with the mindfulness practices of breathing, meditation, and gratitude, to make the programs an experience of mind, body, and spirit. “We know that many people with diabetes and chronic disease often also have depression or anxiety,” says Strople. Tip #1: To help clients reduce stress and boost confidence, Strople suggests they take advantage of free support groups where they can meet others with similar challenges and de

velop new skills, such as goal setting; problem solving around barriers such as financial issues or lack of time; and managing negative self-talk. Tip #2: Remind your clients not to give up or feel guilty if they get off track. Instead, suggest they focus on the positive and what they have accomplished, even if it seems minimal, says Strople. Encourage them to keep working at it, taking small steps to gradually improve eating and physical activity habits to H reach their goals. ■

Barb Gormley

Youville Diabetes Centre

(Winnipeg) The centre educates, encourages, and supports individuals who are learning to effectively manage their diabetes. “In all of our programming, we stress the importance of physical activity because it has such a dramatic impact on our clients’ health,” says Nettie Strople, who manages the programs at its two locations and coaches its healthcare professionals. Its key activity programs are led by a nurse

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JULY 2017 HOSPITAL NEWS 5


IN BRIEF

Researchers discover brain inflammation in people with OCD new brain imaging study by the Centre for Addiction and Mental Health (CAMH) shows for the first time that brain inflammation is significantly elevated – more than 30 per cent higher – in people with obsessive-compulsive disorder (OCD) than in people without the condition. Published in JAMA Psychiatry, the study provides compelling evidence for a new potential direction for treating this anxiety disorder, which can be debilitating for people who experience it. “Our research showed a strong relationship between brain inflammation and OCD, particularly in the parts of the brain known to function differently in OCD,” says Dr. Jeffrey Meyer, senior author of the study and Head of the Neuroimaging Program in Mood & Anxiety in CAMH’s Campbell Family Mental Health Research Institute.

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“This finding represents one of the biggest breakthroughs in understanding the biology of OCD, and may lead to the development of new treatments.”

Inflammation or swelling is the body’s response to infection or injury, and helps the body to heal. But, in some cases, this immune-system

response can also be harmful, says Dr. Meyer, who holds a Canada Research Chair in the Neurochemistry of Major Depression. Dampening the harmful effects of inflammation and promoting its curative effects, through new medications or other innovative approaches, could prove to be a new way to treat OCD. In an earlier study, Dr. Meyer discovered that brain inflammation is elevated in people with depression, an illness that can go hand in hand with OCD in some people. A novel direction for developing treatments is important, since current medications don’t work for nearly one in three people with OCD. About one to two per cent of adolescents and adults have OCD, an anxiety disorder in which people have intrusive or worrisome thoughts that recur and can be H hard to ignore. ■


IN BRIEF

Canada to become 30th country with national dementia strategy

he Alzheimer Society of Canada celebrates the passage of Bill C-233, An Act respecting a national strategy for Alzheimer’s disease and other dementias. Canada will now become the latest country to develop a national dementia strategy to address the overwhelming scale, impact and cost

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of dementia. “For the more than half a million Canadians living with dementia and their families, this is an important milestone,” says Pauline Tardif, CEO of the Alzheimer Society of Canada. “A national strategy enables a coordinated approach to tackling dementia in Canada that will impact the lives of those affected in tangible ways.”

Bill C-233’s co-sponsors, the Honourable Rob Nicholson, MP Niagara Falls, and Rob Oliphant, MP Don Valley West, are to be commended for their leadership and support, as is the Standing Senate Committee on Social Affairs, Science, and Technology. They have been dedicated champions of the Bill on behalf of Canadians living with demen-

Nearly 1 in 2 Canadians expected to get cancer: report early 1 in 2 Canadians is expected to be diagnosed with cancer in their lifetime, according to a new report – Canadian Cancer Statistics 2017 – released by the Canadian Cancer Society (CCS) in partnership with the Public Health Agency of Canada and Statistics Canada. For males, the lifetime risk is 49 per cent and for females it is 45 per cent. This puts an enormous burden on individuals, the healthcare system and services and research supported by cancer chari-

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AN ESTIMATED 206,200 CANADIANS WILL BE DIAGNOSED WITH CANCER THIS YEAR ties. CCS is calling on the public to invest in cancer research and prevention efforts to reduce the impact of cancer on Canadians. CCS emphasizes that the rise in cancer cases is primarily being driven by an aging and growing population. According to today’s report, an estimated 206,200 Canadians will be diagnosed with can-

Today’s Canada Continued from page 4 Providers will also appreciate our accompanying recommendation for more caregiver support. If we acknowledge that family support is essential to support timely and successful discharge from hospitals, we must ensure that families are supported, too. More than 8 million Canadians provide an estimated 1.5 billion hours of home care – more than 10 times the number of hours worked by paid caregivers. Many spend out of pocket to provide supplementary care, medications, food and transportation. Others lose out on wages taking time away from work. Making the Canada Caregiver Credit re-

fundable would provide much-needed financial support, especially to low-income Canadians. More than 50,000 Canadians have joined our Demand a Plan call for a national seniors strategy and we need you to keep the momentum building. Federal Minister of Families, Children and Social Development Jean-Yves Duclos and MP Marc Serré are keeping healthy aging on parliament’s agenda. Progress is happening, but working in direct hospital care every day, we know more must be done. We must continue to press for change because people need H this help today. ■

Dr. Granger Avery is the President of the Canadian Medical Association. www.hospitalnews.com

cer this year, and almost 90 per cent of these cases will be among Canadians 50 years of age. Great progress has been made in the fight against cancer, but there is much more work to be done. • Because of investments in cancer control including prevention, early detection and treatment, the overall cancer survival rate has increased from about 25% in the 1940s to 60% today. • Some cancers, like thyroid and testicular, have a 5-year net survival of over 90%. • For other cancers, such as pancreatic, there is an urgent need for more research investment. Pancreatic cancer has the lowest survival rate of all the major cancers at only 8%. Very little progress has been made against this cancer, especially compared to other major cancers. As a result, it is expected to soon be the third leading cause of cancer death in Canada. • Thanks to the charitable contributions of our donors, CCS invested $40 million in cancer research in 2016. • The Government of Canada invests in cancer control in many ways, including funding the Canadian Partnership Against Cancer and the Canadian Institutes of Health H Research. ■

tia, their families, and caregivers. The Alzheimer Society has long called for a national dementia strategy to enhance research efforts and ensure access to quality care and support so that Canadians with dementia can have the best quality of life. Now that Canada has committed to such a strategy, work begins on implementation. To learn more, H visit www.alzheimer.ca/advocacy. ■

New measures to inform Canadians of the risks of prescription opioids anada is facing an opioid crisis. Overdoses related to opioids are claiming the lives of thousands of Canadians of all ages, and from all walks of life. Some who have become dependent on prescription drugs were not even aware that the drugs they had taken contained opioids. Patients receiving prescription opioids need a clear understanding of the risks associated with these drugs, so they can make informed decisions about how to use them as safely as possible or whether to use them at all. As part of the Government of Canada’s work to reduce problematic opioid use and its related harms, Health Canada is proposing regulations that would make a warning sticker and patient information handout mandatory with all prescription opioids at the time of sale. This means that no matter where patients and families across Canada fill their prescriptions, the same handout and sticker would be provided to them The sticker would be applied by the pharmacist to the prescription opioid container to warn patients about the potential risks associated with opioid use, including dependence, addiction and overdose. The handout would contain broader information on the safe use of opioids, and on the risks associated with these drugs. To finalize these regulations, Health Canada is asking Canadians to provide their comments via the Canada Gazette website. These consultations will be open for a period H of 75 days, ending August 31, 2017. ■

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JULY 2017 HOSPITAL NEWS 7


FOCUS

Advancing cardiovascular care in Northwestern Ontario By Maryanne Matthews he implementation of vascular surgery and on-site endovascular aneurysm repair (EVAR) now available at Thunder Bay Regional Health Sciences Centre is a major milestone in the establishment of a full cardiovascular surgery program for Northwestern Ontario. The Honourable Dr. Eric Hoskins, Minister of Health and Long-Term Care, and the Honourable Bill Mauro, MPP, made a special visit to our Hospital to help celebrate the exciting advancement in comprehensive cardiovascular care. EVAR is a minimally invasive surgery in which a modular stent graph is inserted into the femoral artery and passed up into the weakened part of the aorta. Prior to this development, patients requiring this potentially life-saving procedure had to travel outside of the region to access the service. David Stephens was the first patient to undergo EVAR at the hospital in January 2017, and knows first-hand how important it is to have access to cardiovascular care in the region. “Learning that I could receive my

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(l-r): David Stephens, first EVAR patient at Thunder Bay Regional Health Sciences Centre, Honourable Bill Mauro, MPP, Jean Bartkowiak, President and CEO of Thunder Bay Regional Health Sciences Centre, Honourable Dr. Eric Hoskins, Minister of Health and Long-Term Care, and Dr. Mark Henderson, Executive Vice President of Patient Services at Thunder Bay Regional Health Sciences Centre. treatment here at Thunder Bay Regional Health Sciences Centre was a huge relief,” he says. “Undergoing a medical procedure is stressful enough

without the added difficulties of having to travel and leave your support team behind. I am so thankful for the excellent quality of care that I received right here at home.” “Admission rates for cardiovascular patients at our hospital are well above the provincial average. Our patients and their families deserve local access to care,” says Grant Walsh, 1st Vice Chair, Thunder Bay Regional Health Sciences Centre Board of Directors. “This recent accomplishment reflects our commitment to meet the needs of our region through improved access to cardiovascular care, which will dramatically improve the quality of care and quality of life for thousands of patients.” This accomplishment stems from a partnership with the University Health Network (UHN), which began in 2015. The partnership has and will continue to be instrumental in Thunder Bay Re-

gional Health Sciences Centre’s quest to expand and improve our comprehensive cardiovascular care program in accordance with the Ministry of Health and Long-Term Care, ensuring access to the highest quality of care, close to home. “This is an important step forward for our hospital and we couldn’t have done it without our valuable partners at the University Health Network,” says Jean Bartkowiak, Hospital President and CEO, and CEO of Thunder Bay Regional Health Research Institute. “We are committed to meeting the specialized acute care needs of the people of Northwestern Ontario. The arrival of vascular surgery and the ability to provide potentially life-saving procedures such as EVAR brings us one step closer to where we should be in terms of providing comprehensive carH diovascular surgery, closer to home.” ■

Maryanne Matthews is a communications officer at Thunder Bay Regional Health Sciences Centre. 8 HOSPITAL NEWS JULY 2017

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FOCUS

Heart of the matter:

Providing quality cardiac care to a growing population By Alineh Haidery

illiam Osler Health System (Osler) serves a growing and diverse community with one of the highest rates of heart disease in the country. With its high patient volumes, Osler remains one of the province’s leading cardiac centres providing Percutaneous Coronary Intervention (PCI) treatment. Commonly known as coronary angioplasty, PCI is a non-surgical procedure that opens up blocked blood vessels. It is considered the ‘gold standard’ for individuals experiencing a heart attack due to blocked arteries, and is particularly important at Osler given that the communities the organization serves are at a greater risk of death from heart disease at younger ages than the average Canadian population. Last quarter, Osler saw 75 patients experiencing heart attacks who required emergency angioplasties – the highest local volume of heart attacks for a single health centre in Ontario. Eighty-seven per cent of these patients (65 cases) were treated in less than 90 minutes – the benchmark mandated by Ontario’s Cardiac Care Network. The number of patients requiring angioplasty has grown significantly over the years. Currently, 2,000 angioplasties are performed each year at Osler, up from 1,200 performed just three years ago.

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Dr. Amlani (left) Medical Director, Cardiac Procedures Unit and Dr. Raco, Corporate Chief and Medical Director of Cardiovascular Health System at Osler. “We are serving a growing and diverse population that is at an increased risk for heart disease,” says Dr. Shy Amlani, Medical Director, Car-

diac Procedures Unit at Osler. “Even with the increase in patient volumes, we have been able to maintain short timelines within which we provide

care. These marked reductions in time for treatment are substantial and have the potential to cut mortality rates in half.” Currently, Osler’s cardiac team performs these heart procedures at two catheterization laboratories at Brampton Civic Hospital. Patients from Osler’s other sites – Etobicoke General Hospital and Peel Memorial Centre for Integrated Health and Wellness – also receive care at Brampton Civic’s laboratories. In addition to the labs, Osler has 22 cardiologists working across its three sites, offering a comprehensive range of cardiac diagnostic services, and a pacemaker program to help patients restore normal heart rhythms and support better heart function. So, how has Osler been able to do this? Dr. Dominic Raco, Corporate Chief and Medical Director of Cardiovascular Health System at Osler attributes it to “people power. We are very proud of the great strides the program has made. The level of care being provided has truly been a team effort and is a testament to Osler’s physicians and staff who are committed to providing the best care possible around the clock,” says Dr. Raco. “We work closely with the Emergency Department and EMS and are regularly streamlining processes to be able to provide timely and quality care, and better meet the H needs of our patients.” ■

Alineh Haidery is the Regional Manager, Public Relations at William Osler Health System | Headwaters Health Care Centre | Central West CCAC.

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JULY 2017 HOSPITAL NEWS 9


TRENDS IN TRANSFORMATION

The art of being ‘Lean’: Why Ontario hospitals are ‘going to the gemba’ By Erica Di Maio pen your kimono”: To be honest, open and share your truth. This is how Brenda Kenefick describes one of the defining principles of the Lean Learning Community, a dynamic group of professionals dedicated to fostering a strong learning culture and driving process and quality improvement within Ontario hospitals. In 2015, Brenda, Director, Lean Process Improvement at the University Health Network (UHN), founded the Lean Learning Community. What began as a modest membership of five organizations, including UHN, Quinte Health Care, St. Thomas Elgin General Hospital, Mount Sinai Hospital and Sunnybrook Health Sciences Centre, has expanded to more than 20 member organizations in 2017. “As a community, we tackle the complex challenge of changing attitudes and building a culture of constant improvement – where people and teams begin to see problems as opportunities and feel compelled to make a change – big or small,” says Brenda. “Our goal is to foster an open and honest dialogue around mutual challenges, issues and share best practices we can take back to our teams.” The Lean Learning Community hosts three learning events per year – member organizations take turns hosting events at their respective sites, tackling different themes and high-impact process improvement initiatives. Key topics vary from safety, quality, delivery and efficiency, for example: finding safer and more efficient ways to complete tasks, improving the patient experience, reducing waste and stewarding hospital resources. While event topics and locations change, one fundamental value remains the same: “going to the gemba.”

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‘Going to the gemba’

“Going to the gemba”, a Japanese word meaning “the real place”, refers to

UHN’s Lean team huddles to put their heads together on upcoming process improvement initiatives. the place where work is being done and value is created. From a Lean, hospital perspective, this signifies the importance of seeing a process firsthand, on the frontlines, to fully experience and gain insight into the problem at hand. The Lean Learning Community, a travelling collective, plans its events around site visits, where the hosting member leads the group through a process improvement initiative and tour of selected areas; Community members have the opportunity to discuss change processes with frontline staff and consider how the work might be adopted and translated within their own organizations. Stephen Bell, Manager, Process Improvement at Sinai Health System and member of the Lean Learning Community, emphasizes the important relationship between going to the gemba and value stream mapping, a method of analyzing current state to inform the design of a more efficient future state. “Going to the gemba enables real action and propels transformation,” says Stephen.

“It’s always better to be present, with a well-informed understanding of where the work happens versus imagining what ‘might’ be happening from an office away from the work.” “Stakeholders need to be aligned in their understanding of current state to identify the root cause of the problem. Only then can plans be made to map and shape what a sustainable future process looks like.” One of the biggest challenges faced by many industries, including healthcare, is how to engage employees in a culture of continuous improvement, learning, and sustainability. For Viviane Meehan, Lean Process Improvement Coordinator at Quinte Health Care, being a member of the Lean Learning Community has provided a network of like-minded individuals to discuss important topics like building capacity and engaging employees in process improvement work. She explains the importance of building standard work so that regardless of ‘who’ is on the frontlines on any

given day, quality and safe care is delivered consistently to patients. She’s learned that in order for true change to occur, staff must be engaged and at the forefront of the change process. “Whenever change is required, it needs to happen ‘with staff’ not ‘to them’. Part of the Lean philosophy is to shift our thinking from coming to work and ‘doing our jobs’ to coming to work and being responsible for how we can do our jobs better,” says Viviane. One of the key indicators of process improvement success hinges on its ability to sustain itself. “Once the process improvement team leaves the scene, how does that improvement sustain over time?” says Stephen. “Ensuring owners of the process are educated and equipped to sustain the improvement through monitoring and measurement – and continuing to challenge the process over time – is part of sustaining a lean and learning culture.” To join the Lean Learning Community or learn more, please contact Brenda H Kenefick at askacoach@uhn.ca. ■

Erica Di Maio, Public Affairs and Communications, University Health Network 10 HOSPITAL NEWS JULY 2017

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FOCUS

Let’s boogie! A dance study for people with COPD By Jane Langille

fter showing significant improvement by participating in a formal rehabilitation program, many people living with chronic obstructive pulmonary disease (COPD) find it difficult to maintain their progress when the program ends. A unique feasibility study at West Park is investigating the effectiveness of dancing to music to help people with COPD sustain or improve their level of physical activity post-rehabilitation. COPD is a group of lung diseases that include chronic bronchitis and emphysema, and is the third leading killer of men and women in the world. There is no cure for COPD and it gets worse over time. But with access to rehab, you can slow its progress and improve your quality of life.

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the most COPD inpatient rehab cases of any healthcare centre in the province. Dr. Brooks is collaborating on this research together with Dr. Roger Goldstein, West Park’s Director of Respiratory Medicine and Dr. Kara Patterson, an assistant professor in the Department of Physical Therapy at the University of Toronto. In the study, two groups of 10 participants meet for a 1-hour dance session twice a week for eight weeks. Participants boogie to a variety of different dance styles tailored to their preferences, including tango, contemporary, salsa and cha-cha. They can dance with a class partner or on their own, as they desire. A trained dance instructor with experience working with people with chronic illnesses leads the sessions.

WE ARE MEASURING THE IMPACT OF DANCE ON PHYSICAL ACTIVITY, BALANCE, QUALITY OF LIFE, LIFE SATISFACTION, AND LEVELS OF ANXIETY AND DEPRESSION

“I have been working with stroke patients using dance, so it made sense to see if it might help people living with COPD,” says Dr. Dina Brooks, a Senior Scientist who has been performing research at West Park for over 20 years. “Dance is fun and social. Patients prefer it to exercise on a treadmill or going for a walk. It is also an excellent way to address balance issues, which affect many of these individuals.” Dr. Brooks is also a professor in the Department of Physical Therapy at the University of Toronto.

Study goals

As a result of West Park’s expertise in respiratory rehabilitation, it treats www.hospitalnews.com

“We are measuring the impact of dance on physical activity, balance, quality of life, life satisfaction, and levels of anxiety and depression,” says Dr. Brooks. “We are also tracking participants’ heart rates with Fitbit activity bands, to see if they are getting a good workout.” The study began in April and will extend over the summer. Participants are over the age of 40 and have completed a course of pulmonary rehabilitation at least four months in advance of the dance program. Dr. Brooks has authored or co-authored dozens of studies while at West Park. She currently focuses on research involving individuals

with chronic lung disease and those with cardiovascular disease. She is a Canada Research Chair (Tier 2) in Rehabilitation Chronic Obstructive Pulmonary Disease and the recipient of several teaching and research awards and research grants.

Research award

This study, which is officially called “Let’s Boogie: feasibility of dance in patients with chronic obstructive pulmonary disease,” is supported by a Breathing as One - Boehringer Ingelheim Canada COPD Catalyst Grant from the Canadian Lung Association.

The researchers plan to report on the study results in the fall of 2017. “Learning from this research will inform the program design for a larger, randomized controlled trial in the future,” says Dr. Brooks. “From the smiles and sense of comfort and level of engagement we’ve seen so far in the first group, we hope to confirm that dance intervention can make a meaningful difference in physical fitness, balance, quality of life, anxiety and depression. We think dance may turn out to be an excellent way to help more people with COPD continue to realize their H potential.” ■

Jane Langille is a freelance Toronto writer.

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FOCUS

Dr. Vivek Rao, Division Head, Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network (UHN), displays a Left Ventricular Assist Device (LVAD). The cardiacassist device supports those patients whose heart function is diminished. In the case of patient Marcel Powell, his LVAD helped restore and repair his heart, over several months. Powell eventually had his LVAD explanted or removed after his own heart recovered.

Patient has mechanical cardiac pump removed after failing heart recovers By Stefan Superina

E

very moment of your life is a second chance. Just ask Marcel Powell. The last thing the 27-year-old musician remembers before fainting in the waiting room of the Hamilton General Hospital in May of 2015 is being with his goddaughter and his fiancée, Maria. He awoke five days later in a hospital bed at the Peter Munk Cardiac Centre (PMCC) with a mechanical pump secured to his heart. “Marcel came to us in a severely compromised state,” recalls Dr. Vivek Rao, Division Head, Cardiovascular Surgery at the PMCC. “He was put on immediate life support to maintain blood flow and oxygenation to his body’s vital organs. “He had several blockages in his coronary arteries, which was unusual for a man of his age. There were some prior risk factors that led to this. As a result, Marcel underwent bypass surgery and subsequently needed a mechanical cardiac assist device to maintain his heart function.”

Implant of mechanical heart

On May 28, 2015, cardiovascular surgeon Dr. William Stansfield and a 12 HOSPITAL NEWS JULY 2017

EVERY YEAR IN CANADA, MORE THAN 50,000 PEOPLE ARE DIAGNOSED WITH HEART FAILURE. OF THOSE, 2,000 HAVE ADVANCED HEART FAILURE multidisciplinary team performed a delicate operation to implant the mechanical heart on Marcel’s left ventricle, the lower chamber of the heart that receives blood from the left atrium and pumps it out under high pressure through the aorta to the body. The device uses a tiny, continuously-moving propeller to help blood flow. The mechanical heart would support Marcel’s damaged heart until its function recovered or until a matching donor heart could be found. Like any major medical event, having a mechanical heart implanted and adjusting to life with it was stressful and emotionally difficult for Marcel. The idea of having to learn about a new technology right after heart surgery was at times overwhelming. “I realized I had to make some drastic lifestyle alterations to adjust to life

with the pump and adopt a healthier lifestyle,” says Marcel. “One thing that really kept me going was my artwork. Writing music instilled in me the positive belief that things were going to take a turn for the better.” When one considers the sobering statistics about heart failure in Canada, Marcel’s chances of finding a new heart were dim. Every year in Canada, more than 50,000 people are diagnosed with heart failure. Of those, 2,000 have advanced heart failure. There are approximately 200 heart transplants performed a year in Canada, leaving about 1,800 people across the country still in need of a heart transplant or who could benefit from a mechanical cardiac assist device. Luckily for Marcel, over the course of the next year something truly re-

markable started to take place with his heart – it slowly started to regain its function with support of the device. Indeed, this was a very rare occurrence. There had only been one successful explant of a mechanical heart in the program’s history. “Most of the time when we see native recovery after a mechanical heart implant, it is after a short term,” says Dr. Rao. “We take the patient in, treat them and a week later they are on their way. “In Marcel’s case, we started to notice recovery over a prolonged period of time (several months) to the point that we put him on hold on the transplant list. At his age, it would be much better to have the pump taken out.” A year and four months later, on Sept. 28, 2016, Marcel returned to PMCC to have his mechanical heart removed. It was a complex procedure whereby doctors had to work around a significant amount of scar tissue to partially remove the device. “We essentially turned the pump off and cut off one part of the device so that there was nothing leading into Marcel’s heart anymore,” says Dr. Rao. “For Marcel, it’s important that he still www.hospitalnews.com


FOCUS patients that are eligible for a mechanical heart.”

recognizes that he has a heart problem, has had heart issues in the past, and is still at risk for developing heart issues in the future. He needs to be seen very closely by the PMCC cardiologists to prevent reoccurrence.”

Philanthropic impact

Collaborative expertise

The team effort to save Marcel’s life cannot be overstated. The belief that patients are best served in a team-based approach at the PMCC allows for different perspectives, taking the skills of multiple healthcare professionals and using them on patients with complex problems such as Marcel. “Cardiologist Dr. Phyllis Billia and nurse practitioners Marnie Rodger and Jane MacIver were nothing short of amazing,” says Maria, now Marcel’s wife. “They helped keep Marcel alive, and you can be sure that he will repay that debt by taking better care of his heart.” The Mechanical Heart Program is one of only a few programs in the country that can offer patients like Marcel this life-saving treatment. In fact, it is

Marcel Powell and his fiancée Maria on their wedding day. not uncommon to find transplant cardiologists in other centres across Canada who trained at the PMCC. “We’re hoping to show in the longterm that there will be a cost-saving to

the entire healthcare system because these devices reduce re-hospitalization,” says Dr. Rao. “Because of limited funding in Canada, we’re only doing approximately one per cent of potential

Donors play a vital role in funding these devices. In so doing, they allow the PMCC to provide proof-of-concept to the Ontario Ministry of Health and Long-Term Care to further fund innovative healthcare technology of this kind. It’s an invaluable model very much indicative of what future funding for healthcare technology will look like. Despite all that we can do to encourage the public to register to become a donor, donations for heart organs have not increased. The mechanical heart is a wonderful answer to that problem. And philanthropy is the key to its success. “I was given a second chance at life,” says Marcel. “Not a lot of people on the transplant list get off. I was extremely fortunate. I’m only 27. I still have my entire life in front of me. And the only reason I’m alive today is because of the team at the Peter Munk H Cardiac Centre.” ■

Stefan Superina is a Communications Specialist, Toronto General Western Hospital Foundation.

www.hospitalnews.com

JULY 2017 HOSPITAL NEWS 13


FOCUS F FO FOCU OCU CUS

First-in-Canada implant of novel sensor device at UHN for

heart failure patients By Lianne Castelino and Erica Ngao n a Canadian first, an interventional cardiology team at the Peter Munk Cardiac Centre (PMCC), in collaboration with the Ted Rogers Centre for Heart Research (TRCHR), has implanted a wireless device inside a heart failure patient, enabling clinicians to proactively monitor a patient’s cardiovascular status – virtually and in real-time – with the goal to reduce hospitalizations and re-admissions to hospital, improve quality of life and ultimately, survival. The device, called CardioMEMS HF System, developed by Abbott, was implanted in a 40-year-old male patient in March 2017 at PMCC.

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Diagnosed with heart failure as a result of a heart attack in 2016, the patient, who did not want to be identified by name, underwent an angioplasty (a procedure to widen narrowed or obstructed arteries or veins) at PMCC last year, and was found to have left ventricular dysfunction, weakened heart muscle and coronary artery disease – the most common cause of heart failure. “Heart failure is an epidemic that commonly leads to hospitalization,” says Dr. Heather Ross, scientific lead at the Ted Rogers Centre for Heart Research and cardiologist, Peter Munk Cardiac Centre. “Hospitalization is often necessary when patients start to retain fluid,

THE DEVICE IS DESIGNED FOR A SPECIFIC GROUP OF HEART FAILURE PATIENTS – THOSE IN SERIOUS CONDITION BUT WHO ARE NOT SO ILL THAT THE TECHNOLOGY CAN’T IMPROVE THEIR OUTCOME develop congestion and experience shortness of breath. This technology is a way to directly measure how much fluid is in a patient, allowing us to intervene before they develop symptoms of congestion, before they end up in hospital. This is a big game-changer,” says Dr. Ross.

The CardioMEMS HF System features a small butterfly-like sensor that is implanted, via a catheter-based procedure, into the pulmonary artery (which carries blood from the right ventricle of the heart to the lungs) of a heart failure patient. When the patient lies on an accompanying antenna-equipped

Heart Failure:

The most rapidly rising cardiovascular disease in Canada

1 million Canadians diagnosed

26 million

Global heart failure patients

14 HOSPITAL NEWS JULY 2017

10 days

average length of hospital stay

1.4 million

total number of hospital stays in Canada for heart failure

2.1

average life span of heart failure patient after diagnosis

$3 billion cost to Canadian health-care system

25%

# of heart failure patients who return to hospital within 3 months

50%

heart failure patients who return to hospital within 6 months

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FOCUS In a Canadian first at the Peter Munk Cardiac Centre, in collaboration with the Ted Rogers Centre for Heart Research, a medical team has implanted a wireless device inside a heart failure patient, permitting clinicians to monitor the patient’s cardiovascular status – virtually and in real-time. pillow device, the sensor provides important data – including the patient’s lung pressure readings to clinicians – to a secure website. “It’s going to give us invasive data that we can’t get any other way apart from having the patient in the hospital and having an invasive test to get the information,” says Meredith Linghorne, Nurse Practitioner, Heart Failure, PMCC. “This way we’re getting crucial information about how the patient is doing and we can get it while they’re at home. It will give us pulmonary artery pressure readings that we use to

Courtesy: Peter Munk Cardiac Centre

help decide how well someone with heart failure is doing from a volume perspective. If their pressure readings are very high, it suggests that they’re retaining fluid and we need to make adjustments to their medications,” she says.

The patient is the first among 25 to be fitted with the device over the next nine months. The device is designed for a specific group of heart failure patients – those in serious condition but who are not so ill that the technology can’t improve their outcome.

The device was the subject of the CHAMPION trial in the United States and has been approved by the Food and Drug Administration (FDA) in the U.S. Efforts are underway to seek approval for the device from Health H Canada. ■

Lianne Castelino and Erica Ngao are communication officers at University Health Network.

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JULY 2017 HOSPITAL NEWS 15


EVIDENCE MATTERS

How to treat obstructive sleep apnea: Does the evidence put the issue to bed? By Sarah Garland ou probably know someone who snores. And their snoring may be pretty loud and disruptive. Maybe it’s so disruptive that it’s causing their bed partner – or even those in the next room – to toss and turn. But it’s possible that it’s more than just snoring. They could have a disorder called obstructive sleep apnea (OSA), a condition in which the muscles of the upper airway collapse during sleep, causing their breathing to stop and start. Although OSA is reported to affect around 15 per cent of men and five per cent of women in Canada, the true prevalence may be as high as one in four adults, with many people going undiagnosed. Not everyone with OSA snores, but it is a common symptom. People with OSA may also experience unrefreshing sleep and excessive daytime sleepiness, as well as impaired memory and concentration. It’s hard to overstate the importance of sleep, especially a good night’s sleep; and if left untreated, OSA can lead to stroke, cardiovascular disease, hypertension, diabetes, motor vehicle accidents, cognitive dysfunction, and death. To diagnose OSA, patients are often sent to sleep overnight in a sleep lab,

Y

16 HOSPITAL NEWS JULY 2017

or in some cases technology is available to diagnose OSA in a patient’s own home. Some people may be diagnosed with mild OSA, while OSA in others may be moderate or even severe. One way to measure the severity of OSA is to use the apnea-hypopnea index (AHI), which looks at how often a person stops breathing and how often their breathing becomes very slow and shallow. Typically, AHI scores of 5 to 14 are considered mild OSA, scores of 15 to 29 are considered moderate OSA, and scores of 30 or more are considered severe OSA. A person’s AHI score and

OSA severity can help patients and their healthcare providers make decisions about treatment. What are the options for treating OSA? In Canada, there are a number of ways to treat this sleep disorder. Continuous positive airway pressure (CPAP) devices, which work by forcing air into the upper airway to keep it open, are often considered the gold standard for treatment. There are also other positive airway pressure (PAP) devices that work in slightly different ways, like auto-titrating PAP, bilevel PAP and nasal expiratory PAP (dispos-

able devices that use a patient’s own breath to open up the airway). In addition to PAP devices, there are oral appliances, which work by moving the jaw forward or by holding the tongue back to create space and keep the airway open. Beyond devices, there are surgeries for OSA, the most common being maxillomandibular advancement (MMA), which permanently moves the jaw forward. For adults who are overweight or obese – a risk factor for OSA – other interventions, like diet and exercise, focus on weight loss, which can improve OSA symptoms. With so many treatment options, how do you choose the right one? An important consideration is whether a person will actually use their OSA treatment. Though some consider CPAP the best option for treating OSA, it’s estimated that 29 to 83 per cent of patients don’t use their device regularly as recommended. And it’s not really clear how many patients actually use their oral appliance to treat their OSA. The evidence around how well surgery works to treat OSA and whether it’s safe is also uncertain. There is also the question of whether patients will have to pay out of pocket for their OSA treatment or whether reimburse-

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EVIDENCE MATTERS ment and funding of these different treatment options is available to them. Public coverage for CPAP varies by province, and no provincial programs reimburse oral appliances. Surgery may be covered, if available. To help address the choice of treatment for adults with OSA, CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – conducted an evidence review on the different options for treating OSA. The CADTH report assessed the clinical and cost-effectiveness, safety, and patient and caregiver perspectives and experiences related to the various treatment options for OSA in adults. Ethical issues, implementation considerations, and potential environmental impacts were also addressed. An expert panel, the Health Technology Expert Review Panel (HTERP), reviewed the evidence and developed recommendations for treating OSA.

WITH SO MANY TREATMENT OPTIONS, HOW DO YOU CHOOSE THE RIGHT ONE? AN IMPORTANT CONSIDERATION IS WHETHER A PERSON WILL ACTUALLY USE THEIR OSA TREATMENT The review of the clinical evidence found that all of the treatment options for OSA are effective at reducing excessive daytime sleepiness and the severity of OSA. However, people with severe OSA may benefit more from CPAP than oral appliances. The cost-effectiveness of the treatment options varies by OSA severity. The review also revealed that using the treatments for OSA require people to adapt their daily routines and relationships, and that some people are able to integrate the treatment into their life and experience benefits, while others are unable to do so.

Based on the evidence review, three key recommendations by HTERP emerged. The first being that lifestyle interventions (like diet and exercise) are recommended for adults with mild OSA if they are overweight or obese. For those with mild OSA who are not overweight or obese, no treatment is recommended. The second recommendation is that for adults with moderate or severe OSA, CPAP is recommended; but if the person cannot tolerate CPAP or CPAP is unacceptable, then oral appliances are recommended. Lastly, surgery was not recommended, unless other interven-

tions have failed or are unacceptable to the patient. CADTH’s work, and the recommendations by HTERP, highlight the importance of adapting treatment to a patient’s OSA severity and other patient factors. People may prefer or be better suited to one treatment over another for a variety of reasons, including coverage and reimbursement for the costs of the various treatments, access to dentists and dental health specialists for oral appliances, access to electricity to power CPAP machines, and potential side effects and discomfort experienced from any of the treatments. So what does all this mean to people with OSA, their families, and their healthcare providers? There are effective options when it comes to treating OSA. And CADTH evidence can help guide those treatment decisions. To learn more, visit www.cadth.ca/ OSA or speak to a CADTH Liaison H Officer in your region. ■

Sarah Garland is a Knowledge Mobilization Officer at CADTH.

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COVER

Hypertension

No longer just for adults By Angelique Berg

ong considered an adultsonly condition, blood pressure high enough to be called hypertension is affecting a much younger audience. A member of that audience is Olivia, a delightful 13-year old girl that enjoys life outdoors in her British Columbia neighbourhood. Her recent hypertension diagnosis surprised Olivia’s mother, Rebecca: “It’s common to think of hypertension as an older person’s concern.” Indeed, it’s a common categorization. Even an online search for “hypertension patient” yields images almost exclusively of salt-and-pepper-haired adults. And it isn’t necessarily wrong: over 7.5 million Canadians – one in four adults – has hypertension, the leading global risk for death and disability. The complications to which uncontrolled hypertension can lead are conditions also labelled for older adults, like congestive heart failure, stroke, atrial fibrillation, renal disease, and coronary heart disease. What’s missed is that hypertension now affects our children; one in fifty Canadians under the age of 18. The prevalence of hypertension in Canadian children is closely associated with childhood obesity and sedentary activity patterns in youth. Elevated blood pressure in childhood tracks to adulthood, leading to those serious complications mentioned. Because children with hypertension may already display evidence of target organ damage, prompt identification and treatment is critical. But until recently, primary care practitioners had few, if any, resources to guide them.

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For nearly two decades, Hypertension Canada has produced clinical practice guidelines for hypertension in adults based on a wealth of available, solid evidence. Paediatric literature, however, is inherently limited by small numbers of participants, fewer trials, and a long latency to the development of vascular outcomes. The void was a challenge for kids like Olivia and the primary care practitioners who care for them. “I was lucky,” says Rebecca, “I had terrific support to help get the diagnosis

and to manage the condition, but that’s not everyone’s experience.”

Paediatric guidelines genesis

The increasing prevalence of hypertension in children and the lack of guidance for its management motivated the Hypertension Canada Guidelines Committee in 2013 to establish a subgroup comprising hypertension specialists in paediatric cardiology, paediatric nephrology and nursing to address the void.

Over the next two years, following the highly structured Hypertension Canada Guidelines process, the expert paediatric subgroup systematically evaluated existing literature to create recommendations. In 2015, their draft recommendations passed the rigorous review of the Guidelines Committee’s 75 members, and the first guidelines for blood pressure measurement, diagnosis, and investigation of paediatric hypertension were published in 2016. The next crucial step was to develop management guidance and the 2017

Angelique Berg is the Chief Executive Officer at Hypertension Canada. 18 HOSPITAL NEWS JULY 2017

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COVER

Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Paediatric Hypertension were published this May in The Canadian Journal of Cardiology.

The 2017 Hypertension Canada Guidelines can only be realized with your participation. Here are some things you can do:

THE PREVALENCE OF HYPERTENSION IN CANADIAN CHILDREN IS CLOSELY ASSOCIATED WITH CHILDHOOD OBESITY AND SEDENTARY ACTIVITY PATTERNS IN YOUTH

General principles

The guidelines aim to help primary care practitioners and paediatricians to identify, investigate, and manage hypertension in children and adolescents and to recommend when referral to experts in paediatric hypertension is appropriate. While the 10 guidelines consider specifics of age, sex, height, BMI and others, and are meant to be thoughtfully applied appropriate to the patient and with clinical judgement, some general principles are more broadly applicable. • Measure blood pressure regularly in children three years of age and older. While there are practical challenges to accurately measure blood pressure in infants and very young children, regularly measure those three years of age and older for early identification of hypertension. • Accurate measurement of blood pressure is foundational to treatment. Blood pressure should be measured using standardized paediatric techniques [a standardized approach is included in the guidelines] using a mercury sphygmomanometer, aneroid sphygmomanometer, or oscillometric device. Abnormal oscillometric values should be confirmed with auscultation. • Identification of hypertension as primary or secondary in children is critical. In children less than five years of age, primary hypertension is uncommon, and secondary causes – such as renal, renovascular, endocrine and cardiac disorders – need to be aggressively sought to guide therapy and follow up. Conversely, in obese children and adolescents, primary hypertension is more common than secondary.

Prevention and treatment

The paediatric and adult guidelines share in common the importance of health behaviour modification. The strongest effect on blood pressure in

obese children and adolescents was BMI. With reported associations between childhood blood pressure, diet, and physical activity, studies to modify these risk factors have shown some improvements in markers of cardiovascular health. Evidence for dietary improvements is increasing, showing positive changes with salt reduction and increased potassium found in fruits, vegetables and dairy products. The Dietary Approaches to Stop Hypertension (DASH) diet, which is high in fruits, vegetables, grains, and low fat dairy; and is low in fat, sugar, and sodium, has shown benefits in both adults and children. The combination of dietary improvements as well as physical activity seem to amplify the beneficial effects. While most schools teach healthy eating and physical activity, children with hypertension, obesity, or those at risk for either might benefit from specific advice from primary care practitioners to improve these healthy behaviours.

Future focus

The 2017 guidelines stress that health behaviour modification lies at the foundation, given the noted association of obesity in children and sedentary patterns in youth with hypertension prevalence in children. Fortunately, there are encouraging data suggesting that the prevalence of obesity is stabilizing and that, at least among overweight or obese adolescents in the United States, blood pressure in children is decreasing. “These findings underscore the importance of a continued evidence based approach toward improving the cardiovascular health of Canadian children,” notes Anne Fournier, paediatric subgroup chair, and paediatric cardiologist at the University of Montréal. “The timing of these guidelines is opportune.”

Given the relative newness of these guidelines, and the complexities necessary to consider in treating children, there is much work ahead to help primary care practitioners with their implementation. As a standard practice with Hypertension Canada Guidelines, diagnostic and therapeutic algorithm tools will be developed, and the guidelines will be annually reviewed to capture new evidence as it becomes available. “We’re committed to continual improvement,” says Nadia Khan, president of Hypertension Canada and professor of medicine at the University of British Columbia. “Our goal is to ensure health care professionals are aware of the increased prevalence of hypertension in children and that our guidelines can help them in their treatment decisions to prevent the serious and deadly complications that can emerge much later.” Rebecca is happy to know that new guidelines are now in place to help support children like her daughter, Olivia. “By having guidelines in place, it will help those kids that are being H missed.” ■

• Check out the full paediatric Guidelines at www.onlinecjc.ca • Download the adult Guidelines at guidelines.hypertension.ca. • View the educational resources and videos available at hypertension.ca. • Attend a Hypertension Canada Primary Care Education session near you or online, or the annual Canadian Hypertension Congress. • Become a member of Hypertension Canada for continued updates. Hypertension Canada is the only national non-profit organization dedicated solely to the prevention and control of hypertension and its complications. Powered by a professional volunteer network of hypertension experts, Hypertension Canada develops and produces the nation’s clinical practice guidelines for the prevention, diagnosis and treatment of hypertension. Created by professionals, for professionals, Hypertension Canada’s tools and educational resources help to keep healthcare professionals at the leading edge in hypertension diagnosis and care.

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JULY 2017 HOSPITAL NEWS 19


FROM THE CEO’S DESK

Academic health sciences – now more than ever! By Denis Roy

ast month, I retired as President and CEO of Health Sciences North (HSN) in Sudbury, bringing to a close a career that has spanned 45 years. It is a journey that has taken me from medical student, to graduate researcher, to nephrologist and finally to hospital administrator. Along the way, I have worked with many wonderful and talented people: physicians, researchers, nurses, allied health professionals, support staff, hospital administrators, politicians, civil servants, and most importantly, patients. My years as a hospital administrator, in particular the last 7.5 years at HSN, have reinforced a lot of what I believe about leadership. Specifically, leadership and character are both revealed and proven in times of great challenge. Anyone can command a ship in calm seas. It’s quite another thing to have a firm, confident hand at the wheel when forces beyond your control are pulling you in different directions at the same time. In stormy weather, you need a clear head, a clear focus, a clear direction, and a clear plan to get there. We need that leadership, now more than ever; it is hurricane season in healthcare. Across Canada, hospitals – including my own – are struggling under the weight of demands for care. Patients are backed up in our EDs or placed in hallways and lounges. Beds are occupied by patients who would be better served in other settings, but can’t access the care they need in the community. It’s leading to longer waits for care, surgical cancellations, mounting frustration for patients and healthcare workers, and greater public scrutiny and criticism of governments and healthcare leaders. Under this pressure, it is easy to lose perspective and clarity – of your mission, strategic direction and plan. When you’re being pitched by the waves, there is also the impulse and the political expediency to toss overboard

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Denis Roy

LEADERSHIP AND CHARACTER ARE BOTH REVEALED AND PROVEN IN TIMES OF GREAT CHALLENGE things that don’t appear to be necessary to the situation at hand, such as research, teaching, and investments in innovative new technologies and approaches to care. But these are the things you need in a time of crisis. What you don’t need is to weigh down your institution with outdated thinking and yesterday’s solutions. The father of microbiology, Louis Pasteur, said it best when he said “Knowledge is the torch which illuminates the world.” It is the never-ending quest for new knowledge and innova-

tion which lights the path for breakthroughs in healthcare. The urgent healthcare demands of our time serve as the catalyst for this quest, but they should never extinguish it. I have seen this principle at work repeatedly at HSN. Here are just a couple of examples. For the past year, we have been in a constant state of overcapacity, with anywhere from 20 to 25 per cent of our beds occupied by Alternate Level of Care patients, most of whom are frail seniors. Yet we have devoted significant resources to the im-

plementation of a novel model of care for frail seniors called 48/5. We monitor 5 key indicators within the first 48 hours of admission. As a result, we’re slowing and in some cases reversing the progression of frailty in seniors. It’s reducing both time spent in hospital and readmissions. We have also been conducting research into the effectiveness of a higher-dose flu vaccine for seniors, again with the goal of reducing frailty and hospital admissions due to complications from the flu. We are seeing positive results. These improvements in front-line care would not have been possible had we not established a full-fledged research institute and recruited one of North America’s foremost experts on seniors’ health. It was an investment in difficult times, but it is paying off for our patients and our staff. We have also invested significant resources in expanding our capacity to accommodate and teach both medical learners and our existing clinicians. As a result, more medical learners than ever are spending time with us, and caring for patients while they do. There are voices which say “This is not the right time for the frills of research, teaching, and technology. We need to focus on treating illness, not studying it!” I’m sure Pasteur faced the same criticism. But his quest for new knowledge led to breakthroughs in how we understand and treat illness and infectious disease to this day. Can you imagine a world without vaccination or pasteurization? If now is not the right time for innovation, research and teaching, when is? My time is done. I have fought the good fight. I have finished my race. For my colleagues who remain, I encourage you to stay clear, focused and unwavering in your mission and strategic goals. Let knowledge – through research and teaching – be the torch you carry to illuminate your path toward better H health for the people you care for. ■

Denis Roy was the President and CEO of Health Sciences North. He retired last month. 20 HOSPITAL NEWS JULY 2017

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New procedure reduces need for

open heart surgery By Sharman Hnatiuk ewer patients with coronary artery disease are requiring open heart surgery with the recent introduction of a minimally-invasive technique to bypass severely blocked arteries. Dr. Minh Vo, a newly recruited interventional cardiologist at the Mazankowski Alberta Heart Institute, has been performing a procedure called antegrade dissection re-entry since his arrival last September. Using a catheter inserted through the thigh or wrist, Dr. Vo inserts a mesh tube called a stent along the exterior artery wall on both sides of a blockage, restoring blood flow. The artery heals and accepts the new channel for blood flow. Fifty patients have undergone the procedure, and avoided open heart surgery, over the past eight months. Patients typically experience less pain, have reduced likelihood of complications and recover more quickly than those who undergo open heart surgery. Dr. Vo says the procedure will “change how cardiologists around the world treat patients” with chronic total occlusion (CTO), a complete blockage of a coronary artery caused by a buildup of plaque. One in five patients with coronary artery disease will develop a CTO. “It’s revolutionary and it is something that can work for most patients with CTO,” says Dr. Vo, adding some patients may not be eligible for the procedure and may require open heart surgery. Traditional coronary angioplasty – using a balloon or stent to widen the artery – can be used when an artery is partially blocked but is ineffective when an artery is mostly or fully blocked. Edmonton is the only centre in Alberta, and the fifth in Canada, to offer antegrade dissection re-entry. Studies indicate the use of the antegrade dissection re-entry technique can reduce

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Dr. Minh Vo, interventional cardiologist at the Mazankowski Alberta Heart Institute with Keith Hutchings (patient). the risk of future open heart surgery for patients by 80 per cent. Keith Hutchings, 59, was back at work just one week after undergoing the procedure in February. “I’m already back exercising,” says the Edmonton man. “I’m so grateful this equipment and the expertise were available in Edmonton.” Hutchings began experiencing chest pain last year. An angiogram revealed he had two arteries which were 100 per cent blocked and one that was 90 per cent blocked.

Previously, his best option would have been coronary bypass surgery, where surgeons would perform open heart surgery to create a new pathway for blood to flow to the heart, bypassing the blocked area. Instead, Hutchings underwent antegrade dissection re-entry, which involves a two-hour procedure in the cath lab followed by one to two hours in the recovery bay. “They could only do one artery at a time, but I’m so happy I had the option of two less invasive procedures three

months apart rather than having open heart surgery,” says Hutchings. In January, Dr. Vo became the first in the world to use the TrapLiner, approved by Health Canada that arranges surgical tools in concentric circles inside a catheter. The TrapLiner creates a smaller hole in the artery, which is beneficial for frail, elderly patients who undergo antegrade dissection re-entry. “This novel equipment allows for a safe and successful procedure in a much smaller hole providing more patient comfort,” says Dr. Vo. “This is a

Sharman Hnatiuk is a communications officer at Alberta Health Services. 22 HOSPITAL NEWS JULY 2017

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MINIMALLY-INVASIVE TECHNIQUE USED TO BYPASS BLOCKED ARTERIES, SPEED RECOVERY game changer for patients with complete blockages of the coronary artery.” The Mazankowski Alberta Heart Institute has become one of Canada’s leading heart centres in the prevention and treatment of heart disease and is also the training ground for the cardiac leaders of tomorrow. Dr. Vo will be teaching the antegrade dissection re-entry technique to colleagues and students at the facility, and will continue to teach the technique across Canada, the U.S., and Asia. “This procedure is available in Edmonton thanks to the work of many people,” says Dr. Vo, “and the teams and leaders within Alberta Health Services, the Mazankowski and the cath lab have been instrumental in this endeavour.” Such advanced treatment would not be possible without the support of the University Hospital Foundation, whose donors generously funded the purchase of the equipment in the cath lab. The University Hospital Foundation raises and manages funds to advance patient care, research and healthcare education at the University of Alberta Hospital, the Mazankowski Alberta Heart Institute and the Kaye Edmonton Clinic. Alberta Health Services is the provincial health authority responsible for planning and delivering health supports and services for more than four million adults and children living in Alberta. Its mission is to provide a patient-focused, quality health system that is accessible H and sustainable for all Albertans. ■

New research shows lower rates of gestational diabetes in women exposed to cold temperatures By Kelly O’Brien omen who were exposed to colder temperatures during pregnancy had a lower rate of gestational diabetes than those exposed to hotter temperatures, according to a study published recently in the Canadian Medical Association Journal. The prevalence of gestational diabetes was 4.6 per cent among women exposed to extremely cold average temperatures (equal to or below -10 C) in the 30-day period prior to being screened for gestational diabetes, and increased to 7.7 per cent among those exposed to hot average temperatures (above 24 C). The study also found that for every 10-degree Celsius rise in temperature, women were six to nine per cent more likely to develop gestational diabetes. The study examined 555,911 births among 396,828 women over a 12-year period. All the women studied lived in the Greater Toronto Area, but some

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FOR EVERY 10-DEGREE CELSIUS RISE IN TEMPERATURE, WOMEN WERE SIX TO NINE PER CENT MORE LIKELY TO DEVELOP GESTATIONAL DIABETES were pregnant when the average temperature was warmer, and some when it was cooler. Researchers looked at the relationship between the average 30-day air temperature prior to the time of gestational diabetes screening in the second trimester, and the likelihood of gestational diabetes diagnosis. Dr. Gillian Booth, a researcher at St. Michael’s and the Institute for Clinical Evaluative Sciences (ICES) and lead author of the study, said the finding might seem counterintuitive, but can be explained by emerging science about how humans make different kinds of fat.

“Many would think that in warmer temperatures, women are outside and more active, which would help limit the weight gain in pregnancy that predisposes a woman to gestational diabetes,” says Dr. Booth. “However, it fits a pattern we expected from new studies showing that cold exposure can improve your sensitivity to insulin, by turning on a protective type of fat called brown adipose tissue.” A similar effect was seen for each 10-degree Celsius rise in the temperature difference between two consecutive pregnancies compared within the H same woman. ■

Kelly O’Brien works in communications at St. Michael’s Hospital. www.hospitalnews.com

JULY 2017 HOSPITAL NEWS 23


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World fi rst using Canadian invented device in novel way By Leslie Shepherd hen Dr. Neil Fam examined his 86-year-old patient with severe mitral regurgitation – a condition in which the blood flows backward into the heart after it contracts – his options for treating her were limited. Because of her age and overall health, Ortensia Aceti of Sault Ste. Marie, Ont., was not a good candidate

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for surgery to repair her mitral valve, the flap between the two left chambers of her heart. She had been in and out of hospital with heart failure and medication was no longer controlling her symptoms. Instead, he decided on a catheter-based treatment to guide a MitraClip device to the heart and clamp the leaky valve. The catheter would usually

be inserted through the femoral vein in the leg, but her vein was blocked. “We were locked out, blocked from accessing her heart,” says Dr. Fam, an interventional cardiologist and director of the Cardiac Intensive Care Unit of St. Michael’s Hospital in Toronto. Dr. Fam recalled a conversation he had about a year previously with Baylis Medical Company, Inc., a Ca-

nadian supplier of high-tech cardiology equipment, about one of their devices that was designed to achieve access to the heart from alternative approaches. For the first time in the world, Dr. Fam successfully used the company’s SupraCross RF Solution to guide a MitraClip device through the jugular vein – a more direct route to the heart – and

Can hockey save the Canadian healthcare system? By Dr. Stephen Pinney he Canadian healthcare system is founded on great ideals: high quality care, public funding, and universal access. Ideals notwithstanding, the reality is that Canada’s healthcare system is plagued with long wait lists, lack of primary care access, inconsistent care quality, and rising costs. Can hockey, Canada’s game, provide the answer to the nation’s healthcare woes? The past two decades have seen a movement to fundamentally reform healthcare delivery – almost everywhere except Canada. The impetus for these sweeping changes includes the realization that traditional healthcare delivery – where individual physicians working autonomously in isolated practices, leads to wide variations in care that is costly, not evidence-based, and has an unacceptably high rate of medical errors. Fee-for-service reimbursement has resulted in an emphasis on the volume rather than value of care. Failure to adequately measure the results of care has limited opportunities to continuously improve performance. Recognizing these dysfunctional elements of 20th century healthcare, it has been proposed that 21st century health systems need to be organized differently. Key changes include: 1. A primary orientation to the entire episode of care, focusing on (and

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FEE-FOR-SERVICE REIMBURSEMENT HAS RESULTED IN AN EMPHASIS ON THE VOLUME RATHER THAN VALUE OF CARE... HOCKEY PROVIDES AN ANALOGY FOR UNDERSTANDING HOW OUR SYSTEM NEEDS TO CHANGE measuring) patient outcomes rather than emphasizing isolated fragments of care (clinic visits, tests, etc). 2. A team-oriented approach to care delivery (with an emphasis on primary care) to replace the traditional isolated physician model. 3. A population-based approach where proactive strong health system leadership organized care around individual patients and populations. With few exceptions these changes have not occurred in Canada. The country’s vaunted system has become a prisoner of its own history. Hockey provides an analogy for understanding how our system needs to change. Successful professional hockey teams embrace certain principles that Canadians take for granted. Successful modern healthcare systems must do the same. Imagine treating a patient with an illness or a surgical problem as the equivalent of a hockey game. Teams focus on winning games and being suc

cessful throughout the entire season. This requires high performance levels in various skills by outstanding players in a coordinated team. Patient care requires a similar approach. For most medical problems, multi-disciplinary skilled practitioners must work in a coordinated manner under clear team leadership to ensure successful patient outcomes. Hockey coaches measure results and player performance, and make changes accordingly to improve future games. Similarly, healthcare must accurately measure care results and make progressive changes for improvement, including replacing underperforming providers or team management. Those leading the NHL make decisions based on the best interest of the whole league. An equivalent approach is critical in modern healthcare. System leaders must work on behalf of patients and taxpayers by proactively identifying population health needs, creating programs (teams), and assembling resources to meet these needs.

However, making the essential changes that would promote integrated care delivery and a population-based approach has been challenging in Canada. Most hospitals still receive lump-sum yearly payments, which reinforce the status quo and stifles innovation. Fee-for-service physician payment rewards doctors for high volume fragmented care and precludes integrating physicians into team-based care. These historical payment methods are not based on normal patient flows and population needs. They must change. To match reality with the ideals, take a page out of the hockey playbook and fundamentally reform the health systems organization and funding mechanisms. Rather than directly confronting the existing entrenched system head-on one option for reform is the formation of a second public healthcare system based on these principles. A coordinated outcome oriented team-based system that would supplant the existing fragmented system over time. However, major reform will only occur when citizens push their provincial and federal leaders for changes. This time is approaching as more Canadians realize that we cannot expect a different result from a system that keeps doing the same old H things. ■

Stephen Pinney MD is the author of How Hockey Can Save Healthcare: A Principle-Based Approach to Reforming the Canadian Healthcare System. 24 HOSPITAL NEWS JULY 2017

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FOR THE FIRST TIME IN THE WORLD, DR. FAM SUCCESSFULLY USED THE COMPANY’S SUPRACROSS RF SOLUTION TO GUIDE A MITRACLIP DEVICE THROUGH THE JUGULAR VEIN successfully repair Mrs. Aceti’s leaking mitral valve. Dr. Fam notes this was possible, despite the awkward angle of the jugular vein in relation to the heart, because the tip of the sheath is steerable and the wire is equipped to deliver radiofrequency energy to puncture the septum of the heart. This allows the physician to position the system appropriately from this challenging angle and puncture the septum of the heart in a precise and controlled manner without using excessive force. The septum is the dividing wall between the left and right sides of the heart and it’s the last barrier to getting to the mitral valve, which sits between the left ventricle and the left atrium.

Dr. Fam says Mrs. Aceti had no complications and her condition improved, allowing her to be discharged to her home. At a followup appointment, she was doing well with no further heart failure. Sue Carlucci, one of Mrs. Aceti’s three daughters, said that Dr. Fam explained the novel procedure to the family carefully in advance. “If Dr. Fam hadn’t suggested this procedure, we probably would have lost our mom,” she says. “He’s our angel,” she adds, referring to St. Michael’s nickname, the Urban Angel. Dr. Fam says that while this procedure would be appropriate for only se-

Dr. Neil Fam is an interventional cardiologist and director of the Cardiac Intensive Care Unit of St. Michael’s Hospital in Toronto. lected patients, they are high-risk patients for which there may be no other treatment options. “Given the success of this procedure, the door is open for future studies of

the jugular approach for treating the mitral valve,” he said. Dr. Fam has published a report of this procedure in the journal H Eurointervention. ■

Leslie Shepherd is Manager, Media Strategy at St. Michael’s Hospital.

www.hospitalnews.com

JULY 2017 HOSPITAL NEWS 25


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Lean approach

to reduce surgical wait times at NBHC

By Melissa Stark

ntil recently, like many other hospitals across Canada, the New Brunswick Heart Centre (NBHC) faced ongoing challenges with surgical wait times. Despite the implementation of various initiatives aimed at addressing the issue, patients still waited too long for cardiovascular surgery and the number of patients on the wait lists continued to grow. Now that has started to change and the hospital is making substantial progress in delivering quality care in a more timely manner, thanks to a collaboration with the regional health authority, Horizon Health Network, and Medtronic Integrated Health Solutions (IHS), a division of the global medical device manufacturer Medtronic plc, which partners with healthcare providers to help them enhance access, cost and care. NBHC is a provincial centre of excellence and the only provider of adult tertiary cardiac care for New Brunswick and Prince Edward Island. Located within the Saint John Regional Hospital (SJRH), it delivers a wide range of cardiac care and support services to more than 17,000 patients annually, and is responsible for meeting an ever-growing demand for advanced care within its existing budget. Under a five-year partnership that began in May 2016, Horizon and Medtronic IHS are working together to improve access to five clinical services provided at NBHC. They identified cardiovascular surgery wait times as the most pressing need and the focus of the first phase of the collaboration. More than 800 cardiovascular surgeries are performed at NBHC each year. Meeting the Canadian Cardiovascular Society’s guidelines for recommended maximum wait times has been an ongoing challenge. The new partnership aimed to address the issue by applying Lean Six Sigma principles of continuous improvement to optimize the processes involved and in order to

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Michelle Brodersen, BNRN 5BN Resource Nurse, JulieAnna Lent, BNRN Charge Nurse and Christine Landry, Ward Clerk

improve the patient experience, clinical productivity and quality of care. Many people were involved in the initiative, including teams from Horizon and Medtronic IHS as well as senior administrative and clinical leaders, physicians and staff from NBHC and SJRH. Under the direction of a steering committee, a core team oversaw the activities of individual project teams composed of more than 50 subject matter experts who worked on the design and execution of the various aspects of the project. The planning stage included a review of current programs and operations at NBHC, interviews with key stakeholders and data analysis. One Kaizen (continuous improvement) team focused on optimizing surgical processes, all the way from the initial decision to operate to the completion of the procedure, while another concentrated on all activities related to patient flow before and after surgery. The planning culminated in a fourday Kaizen workshop where the teams

defined and analyzed their findings and identified areas for improvement. For example, one key problem area was capacity in the intensive care unit (ICU), which frequently led to operating room (OR) cancellations. The teams also prioritized solutions, identified potential risks and developed detailed action plans with the owners of each process. In addition, they linked the solutions they developed to overall business goals and objectives. Four key areas of focus emerged from the workshop: increasing OR capacity, reducing OR cancellations, reducing average length of stay (ALOS) in the ICU, and reducing ALOS in the step down unit. Then the execution of the plans began. Progress was monitored regularly and challenges were reviewed and managed. A weekly dashboard reported key performance indicators (KPIs), providing visibility for individual aspects of the project as well as timely feedback on overall effectiveness.

The results of this initial phase of the project have been impressive. Within the first six months after the Kaizen workshop, OR capacity was increased by 14 per cent, median wait times were reduced by 44 per cent from 118 to 66 days, and 90th percentile wait times fell by 31 per cent from 283 to 195 days. These trends are expected to continue as time goes on. Significant improvements in the number of cases waiting in the queue has yet to be realized, but are expected. Through increasing NBHC’s capacity and efficiency in handling patients, the project has improved the quality of care, provided insights that will be invaluable in controlling costs in the future, and further promoted a culture of continuous improvement within the organization. This initiative has demonstrated that innovative partnerships with health organizations, healthcare professionals and industry can lead to better care for patients, while improving efficiencies and ensuring sustainability of H healthcare services. â–

Melissa Stark is a Process Improvement Facilitator at Horizon Health Network. 26 HOSPITAL NEWS JULY 2017

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Annual Report On Paediatric Care In Health Care Centres Across Canada.

KǀĞƌϲϬ͕ϬϬϬĚĞĚŝĐĂƚĞĚƌĞĂĚĞƌƐĞǀĞƌLJŵŽŶƚŚ͊ /ŶĨŽƌŵ͕ĞĚƵĐĂƚĞ͕ƉƌŽŵŽƚĞĂŶĚ ďƵŝůĚLJŽƵƌďƌĂŶĚǁŝƚŚ,ŽƐƉŝƚĂůEĞǁƐ͘ JULY 2017 HOSPITAL NEWS 27


FOCUS

Patient-centred

diabetes care at Runnymede By Michael Oreskovich

B

y the end of this decade, a staggering one in 10 Canadians is expected to have diabetes. Such high prevalence comes at a great personal cost; if the disease isn’t well-managed, it causes organ damage, blindness and even limb loss. The financial toll diabetes takes on the healthcare system is also severe. In 2012, $12.2 billion was spent in Canada to treat the disease, an amount that will rise annually as diagnoses climb. It’s crucial to find innovative solutions for managing the disease both effectively and sustainably. One way Runnymede Healthcare Centre meets this challenge is by leveraging the unique expertise of its clinical registered dietitians (RDs). As certified diabetes educators (CDEs), the hospital’s clinical RDs are ideally positioned to facilitate coordination among interprofessional team members to manage the disease. The result of this collaboration is improved quality of life for patients, less reliance on medication and shorter hospital stays. Diabetes is a chronic disorder in which sugar accumulates in the blood instead of being converted to energy, either because the body doesn’t produce insulin or can’t use the insulin it makes. “About one-third of our patients are diabetic, so controlling the disease is a high priority,” says Sharleen Ahmed, Runnymede’s Vice President of Strategy, Quality and Clinical Programs. “Patient-centred therapeutic diets contribute to the maintenance of stable blood sugar levels, which helps patients benefit as much as possible from rehabilitation so they can return home from hospital sooner.” The scope of practice of clinical RDs goes a step beyond at Runnymede because of the team members’ CDE designations. The CDE credential is earned through education that broadens knowledge of diabetes care across multiple disciplines, including pharmaceu-

tical therapies. This advanced expertise makes the clinical RDs ideal point-people for overseeing management of the disease at the hospital. The skills and knowledge gained from CDE training enable Runnymede’s clinical RDs to prepare and recommend diabetes treatment plans that ‘connect the dots’ across disciplines. Ultimately these plans are finalized by the hospital’s physicians, but the clinical RDs’ unique perspectives play a significant role in facilitating collaboration within the interprofessional team and place a strong emphasis on proper nutrition. To illustrate this, Janna Kwong, professional practice leader for Runnymede’s clinical RDs, points to a patient the team recently treated. “He was getting daily insulin injections to manage his diabetes for years, but after examining his dietary habits here, we

collaborated with the interprofessional team and found ways to adjust what he ate so he could take an oral medication instead for stabilizing his blood sugar.” The positive impact of this change on the patient’s experience was profound. “Afterward, every time I’d see him, he’d always stop me to say how happy he was about not having to take daily insulin injections anymore.” The CDE designation also enhances the clinical RDs’ role as educators for patients and their families. By teaching self-management techniques, the team members help patients gain control of their disease. “We increase patients’ awareness of how their food choices impact their disease,” says Kwong. “We give them the education and tools they need so they’re able to continue with the good dietary habits we start them on here at Runnymede.” This support

enhances patients’ independence and increases safety after discharge. Harnessing clinical RDs’ specialized skills as CDEs is a leading-edge solution Runnymede uses for managing diabetes. It enhances sustainability in the face of rising costs by keeping medication use to safe minimums where appropriate and increasing the efficiency of clinical staff through improved collaboration. Ahmed, however, is quick to say the hospital’s efforts are about patient-centred care, first and foremost. “The team’s approach enhances quality of life and safety, and contributes to patients achieving their rehabilitation goals sooner so they can resume their lives,” she says. “The education our clinical RDs provide to patients ensure healthy dietary habits are continued after discharge, so they can safely manage the disease on their own and H be as independent as possible.” ■

Michael Oreskovich is a Communications Specialist at Runnymede Healthcare Centre. 28 HOSPITAL NEWS JULY 2017

www.hospitalnews.com


DOCTORS WITHOUT BORDERS Photographer: Louise Annaud/MSF

MSF teams in and around Mosul have received more than 1,800 patients in need of urgent or lifesaving care in the last two months. 1,500 of them needed treatment for conflict related trauma. As the scale of the non-trauma needs also became apparent, MSF opened maternity services in eastern Mosul at the beginning of February, and since then the teams have assisted 100 births and performed 80 C-sections.

Treating civilians caught in crossfire in Mosul, Iraq By Claudia Blume t the end of February 2017, a few days after Dr. Rogy Masri arrived in Mosul, Doctors Without Borders/Médecins Sans Frontières (MSF) opened what was, at the time, the city’s only fully functional, 24-hour hospital, in a former retirement home. Iraq’s second-largest city used to have an advanced medical infrastructure, but since the so-called Islamic State (IS) took control of Mosul in June 2014, most hospitals have either been burned or destroyed. The Iraqi government launched a military campaign to retake Mosul last October, and fighting continues in different parts of the city. In recent months, MSF has attempted to fill some of the most critical health gaps, working in several medical facilities in and around the city to provide emergency and surgical care, post-operative care and maternity services for at-risk patients. MSF teams are also providing care for children suffering malnutrition, as well as primary health-

A

care and mental health support in camps for people fleeing Mosul. Dr. Masri, an emergency physician from Toronto, worked in the hospital and other medical facilities in retaken East Mosul, and also in medical posts in the Western part of the city, which provide emergency trauma care to people wounded in the near-constant fighting. During his two months in Iraq, Dr. Masri heard countless heart-wrenching testimonies from patients who had lived through the conflict. “Everyone had lost someone in a violent way, everyone had witnessed a lot of death and torture”, he remembers. He particularly remembers one patient with heart problems, who also had kidney failure. The closest hospital offering dialysis was at least four hours away, and he told the man’s family that he would most likely not survive the drive, offering to keep him comfortable with pain medication in the clinic in East Mosul instead. “His son told me that the man and

his wife had already watched two of their sons get beheaded and that the family would take the risk, accepting the potential death of another family member, because they were tired of watching their family members die.” Dr. Masri says. Working in East Mosul – where the sound of shooting, explosions and drone attacks on both sides of the city’s dividing line was almost constant – was often nerve-wracking, but Dr. Masri says that many trauma patients would most likely have died without the MSF hospital. When he first arrived, there was no night-time healthcare available for the citizens of Mosul. When MSF opened a 24/7 hospital, on March 1, 2017, local staff were afraid to work overnight, fearing it was still unsafe. But they were so dedicated to providing healthcare and helping people in the community that they agreed to work the night shifts. They were accompanied by expatriate MSF staff, including Dr. Masri, who also stayed

with them in the hospital. “We wanted them to know that we supported them fully, and that we were in this together,” Masri pointed out. “That was probably the most touching moment for me. You know that none of them were doing it for a paycheque – they genuinely cared about getting their city back on its feet,” he says. Dr. Masri says he was deeply impressed by the tireless, selfless work of his Iraqi colleagues. “I have never seen so much dedication and passion,” he says. “One doctor told me: ‘You know, I felt as though I was dead for the past two and a half years. I could not leave my house, because there was a chance that I or one of my family members would die for something so trivial. This is the first chance I have had to be alive again, so I now want to do everything I can.’ ” Despite all the trauma the citizens of Mosul have endured, Masri felt that MSF’s life-saving presence there is H contributing to a sense of hope. ■

Claudia Blume is a Press officer at Doctors Without Borders/ Médecins Sans Frontières Canada. www.hospitalnews.com

JULY 2017 HOSPITAL NEWS 29


A column where industry leaders address key issues in healthcare.

Contact editor@hospitalnews.com for availability.

The engaged workforce:

Why it’s not just HR’s concern By Spiros Paleologos anadian healthcare organizations continue to face numerous challenges, both internally and externally. They continually struggle to balance costs and quality of care, as demands surge but funding does not keep pace. They also need to successfully maintain an efficient and productive nursing corps while regularly attracting fresh talent. And attracting that quality talent is becoming an increasingly challenging task, given the ever-increasing workload, much of it administrative in nature. These challenges are not mutually exclusive – and they’re not just a concern for HR leaders – as various studies have shown a direct correlation between employee engagement and improved quality of care.

C

Absenteeism and overtime

In healthcare specifically, a 2016 study by the Canadian Federation of Nursing Unions revealed that absenteeism and overtime, a manifestation of disengagement, are a growing and alarming problem. According to the report, public sector healthcare nurses’ absenteeism rate is 8.7 per cent on average, up from 7.9 per cent in 2014. This rate of absenteeism is substantially higher than the average of all other occupations (5.7%). In fact, hours lost due to illness or disability is equivalent to the annual workload of almost 15,900 nurses. In other words, 28.8 million work hours must be found to replace those workers who are absent. Finally, the annual cost of absenteeism to the healthcare system is conservatively estimated at $989 million a year in 2016, assuming 49 working weeks in one year, compared to $841 million in 2014.

As absenteeism rates rise, so too does overtime. Aggregating both paid and unpaid overtime in 2016, public sector healthcare nurses worked an estimated 20.1 million hours annually, compared to 19.1 million hours worked in 2014. This number is equivalent to 11,100 full-time positions at an estimated cost of $788 million attributable to paid overtime, plus $180 million of unpaid overtime borne by nurses. This data is supported by a global study from The Workforce Institute at Kronos and Coleman Parkes Research. • 52% of respondents find managing absenteeism to be a truly challenging experience • 73% cite increased employee absence as a core disruption impacting their work • 73% say unplanned absences are their biggest workforce management challenge While the absenteeism problem in Canadian healthcare needs to be addressed at its root cause, the good news is that relatively small, incremental changes can reap big rewards in the short term and help inform broader, deeper changes over time. Many organizations turn to Human Capital Management (HCM) and

workforce management (WFM) technology to automate activities such as data collection, forecasting, budgeting, and scheduling. At their core, these tools alleviate the administrative burden across the organization, deliver actionable insights to senior management, and allow employees to have greater visibility and control over their work and schedules. By deploying such tools, performance and competency improve by avoiding non-productive and time-wasting processes that could negatively impact an establishment’s budget. The transparency enabled by automated schedules made visible to all fosters greater employee engagement. Organizations need to evaluate current (and future) systems with three key stakeholders in mind: executives, front line managers, and employees.

Executives: Is the bottom line enough?

Fifty-eight per cent of employees think their CEO is focused on finances rather than employees. This may seem a rather harsh evaluation of a position whose purpose is to focus on business performance, yet it’s fair to say it may be difficult to juggle staff concerns while keeping an eye on the bottom line. Modern WFM technologies can help alleviate some of this pressure. Analytic dashboards can provide greater insight into real-time costs, and forecasting of business outcomes across the entire organization. This data helps executives proactively address situations before they negatively impact results, while also offering a window on some of the issues facing employees. Unfortunately, this level of executive involvement with WFM is still rare,

with only five per cent of organizations in Canada today operating at this level. While organizations continue to use manual processes and/or outdated technologies, it may make it difficult for senior executives to have more direct involvement in fostering employee engagement.

Front line managers: Caught in the middle?

Often the intermediaries between senior management and employees, it’s not unusual for nurse managers to find themselves in the middle between executives’ demands and nurses’ needs. WFM technologies can give managers instant access to insight and analysis enabling them to proactively address critical issues and challenges before short and long-term goals are compromised. Additionally, WFM can help to ensure proper staffing levels and support to meet and manage patient demand and executive expectations. Current data shows only 20 per cent of organizations are operationally efficient, with outdated systems and technology again being one of the main stumbling blocks.

Employees: Handle with care

The majority of employees strive to be recognized as an asset to their organization, but can often be hampered by tedious administrative tasks. Respondents to the ‘$88 Billion Question’ survey cited two key factors that would increase employee engagement: More empowerment in their role and more visibility and flexibility in scheduling. Automating scheduling and basic time and attendance processes such as timesheets, electronic approvals, and conditional workflows can significantly

Spiros Paleologos is the Vice President and General Manager for Kronos Canada. During his 20 years of leadership, Spiros has grown Kronos Canada to be the leading provider of Workforce Management solutions in Canada. 30 HOSPITAL NEWS JULY 2017

www.hospitalnews.com


0.076 lower administrative effort and costs, and increase efficiencies. Hospitals using WFM solutions report reductions in agency fees of up to 50 per cent, and in overtime of up to 30 per cent. But this is merely the first step. Organizations can then focus on integrating more complex workforce procedures into the organization’s clinical, financial or production systems. Benefits include: • Deeper insight into employees’ performance and productivity by management; • Automation of burdensome tasks for employees (such as scheduling), allowing them to focus on value-add tasks that help deliver results and exceptional patient care, • Enhanced communication with employees for greater transparency. The end result is more employee empowerment, with a stronger determination to deliver on tasks and goals. It’s easy to say organizations need to evaluate the current state of their WFM processes, but in reality it’s a multi-stage journey that, despite its complexity, can be achieved by following these three steps:

1) Begin with the ‘low-hanging’ fruit and automate tactical procedures, such as timesheets, schedules and business rules; 2) Once that foundation has been set, begin integrating with other systems for deeper insights into performance and impact on the quality of care; and, 3) Shift to a level of analytic capability that provides: a. Ability to identify trends and patterns across an organization’s most important metrics b. Exposure to underlying issues and opportunities to improve productivity and quality of service c. Transparency so employees and managers alike are better equipped to make data-driven decisions on key issues impacting performance and operational outcomes By following these steps, while constantly keeping in mind the needs of executives, management and employees, organizations can begin to reap the full benefits of WFM that will help them realize an unprecedented level of workH force engagement. â–

Sp e c i a l Fo c u s f or S e p t e m b e r 2 0 1 7 Is s u e

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�

QAugust 8–10, 2017 FIME – Largest Medical Trade Exhibition Orlando, Florida :HEVLWHZZZÀPHVKRZFRP QAugust 20–23, 2017 CMA 150th Annual Meeting & General Council QuÊbec Convention Centre, QuÊbec City :HEVLWHZZZFPDFD QSeptember 21–23, 2017 2017 NPAO Annual Conference The Sheraton Centre, Toronto Website: www.npao.org QSeptember 26–27, 2017 WK$QQXDO1DWLRQDO)RUXPRQ3DWLHQW([SHULHQFH Holiday Inn Toronto International Airport, Toronto :HEVLWHZZZSDWLHQWH[SHULHQFHVXPPLWFRP QSeptember 28, 2017 EMR: Every Step Conference Toronto Congress Centre, Ontario :HEVLWHZZZRQWDULRPGFD QOctober 22–24, 2017 CAPHC Conference Montreal, QuÊbec Website: www.caphc.org

Online Healthcare Education In our September edition of Hospital News, we will focus on unique opportunities available to the health care industry for continuing online education. 6USPULLK\JH[PVUWYV]PKLZ[OL\UPX\LVWWVY[\UP[`[VHJOPL]L[OPZ^P[OĂ…L_PISLSLHYUPUN ZJOLK\SLZHUKHZLSLJ[PVUVMJV\YZLZUV[HS^H`ZH]HPSHISLPUHZWLJPĂ„JYLNPVU

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QOctober 23–24, 2017 3DWLHQW(QJDJHPHQW 2XWFRPHV7DNLQJLWWRWKH1H[W/HYHO Toronto, Ontario :HEVLWHZZZFDSWDFWSFRP QOctober 24–25, 2017 2nd Annual Canadian Healthcare Infastructure Toronto, Ontario :HEVLWHZZZFDQDGLDQLQVWLWXWHFRP QOctober 26–27, 2017 3DHGLDWULF(PHUJHQF\0HGLFLQH&RQIHUHQFH Peter Gilgan centre for Research and Learning, Toronto :HEVLWHZZZVLFNNLGVFD Q November 6–7, 2017 HealthAchieve Toronto, Ontario Website: www.healthachieve.ca Q November 13–16, 2017 0(',&$²:RUOG)RUXPIRU0HGLFLQH ' VVHOGRUI*HUPDQ\ :HEVLWHZZZPHGLFDWUDGHIDLUFRP To see even more healthcare industry events, please visit our website www.hospitalnews.com/events

JULY 2017 HOSPITAL NEWS 31


BIOMED PRESENTS...

MEMORY, FORGETFULNESS, & THE BRAIN A Seminar for Health Professionals TUITION $109.00 (CANADIAN)

Conference registration is from 7:45 AM to 8:15 AM. The conference will begin at 8:30 AM. A lunch break (on your own) will take place from approximately 11:30 AM to 12:20 PM. The course will adjourn at 30DWZKLFKWLPHFRXUVHFRPSOHWLRQFHUWLÂżFDWHVDUHGLVWULEXWHG

Registration: 7:45 AM – 8:30 AM Morning Lecture: 8:30 AM – 10:00 AM z Memory and the Brain: Forming, Storing, and Retrieving Memory. z Memory and Behavior: +RZ3HUFHSWLRQ7KLQNLQJDQG(PRWLRQV,QĂ€XHQFH0HPRULHV z Declarative and Procedural Memory: How We Remember Facts and Movements. z Episodic and Semantic Memory: How Time Affects Memories. z Sleep Well and Remember Well: The Importance of Sleep in Strengthening Memories. Mid-Morning Lecture: 10:00 AM – 11:30 AM z “Flashbulb “Memories of Emotional Events Like 9/11: How Accurate Are They? Do These Memories Change Over Time? z How Stress Affects Memory and Controversies Around Memory: False Memories, Eyewitness Testimony, and Recovery of Repressed Childhood Memories. Memory and Survival. z What is Confabulation? Is it a Memory Disturbance or a Deliberate Lie? z How We Retrieve Memories: Free Recall vs. Recognition. Re-Retrieval and Re-Consolidation. z Why Do We Forget? Is Forgetting Necessary? Decay vs Interference. Lunch: 11:30 AM – 12:20 PM Afternoon Lecture: 12:20 PM – 2:00 PM z When We Cannot Forget: Memory Savants and PTSD “Flashbacks.â€?

The “7 Sins of Memoryâ€?: Why Memory Fails Us When We Need It. The Effects of Aging on Memory: Normal Forgetting, Age-Associated Memory Impairment, and Mild Cognitive Impairment. z Do We Know When Memory is Declining? Are Self-Administered Tests of Memory Reliable? z Ways to Improve Memory and Minimize Decline: Healthy Living and Lifelong Learning. z Types of Amnesia: Psychogenic vs. Organic Amnesia. Dissociative Amnesia (DSM-5) and Multiple Personality (Dissociative Identity Disorder). Anterograde, Retrograde, and PostTraumatic Amnesia. Transient Global Amnesia. Mid-Afternoon Lecture: 2:00 PM – 3:20 PM z Severe Amnesia Syndromes: Wernicke- Korsakoff Syndrome and Herpes Simplex Encephalitis. z Common Medical Conditions and Memory Loss: Anemia, Thyroid Disorders, Sleep Apnea,   $Q[LHW\ 'HSUHVVLRQ+HDUW'LVHDVH3URORQJHG$QHVWKHVLDDQG3RVW+RVSLWDO6\QGURPH z Medications, Memory Loss, & Reversible Memory Disorders: The Obvious Culprits: Drugs, Alcohol, Smoking, Chronic Stress, Normal Pressure Hydrocephalus, Sleep Disorders, and   'LHWDU\'HÂżFLHQFLHV z How Memory Loss Compromises Dental Care: Treating Patients With Memory Loss And Dementia. z Helping Patients and Caregivers Cope. Evaluation, Questions, and Answers: 3:20 PM – 3:30 PM z z

Biomed’s Website: www.biomedglobal.com

MEETING TIMES & LOCATIONS EDMONTON, AB

Wed., Oct. 18, 2017 8:30 AM to 3:30 PM Radisson Hotel 4520 76th Avenue Edmonton, AB

RED DEER, AB

CALGARY, AB

Thu., Oct. 19, 2017 8:30 AM to 3:30 PM Radisson Hotel 6500 67th Street Red Deer, AB

Fri., Oct. 20, 2017 8:30 AM to 3:30 PM Executive Royal Inn 2828 23rd Street NE Calgary, AB

INSTRUCTOR

Dr. R.S. Hullon (M.D., J.D.) is a full-time physician-lecturer for INR-Biomed. 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, Parkinson’s, and Alzheimer’s diseases) and psychiatric disorders (personality and mood disorders). His medical experience also includes diagnostic laboratory work, particularly in hematology. Dr. Hullon has had extensive surgical experience in trauma management and orthopedics and has published papers on head, back, and knee disorders and pain medications. He has also studied bovine spongiform encephalopathy (BSE or mad cow disease) and the medical and legal implications of this disease. Biomed reserves the right to change instructors without prior notice. Every instructor is either a compensated employee or independent contractor of Biomed.

FEE:

CHEQUES: $109.00 (CANADIAN) per person with pre-registration or $134.00 (CANADIAN) at the door if space remains. CREDIT CARDS: Most credit-card charges will be processed in Canadian dollars. Some charges will be in U.S. dollars at the prevailing exchange rate. 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 INFORMATION NURSES (RNs, RPNs, & LPNs)

 7KLVSURJUDPLVGHVLJQHGWRSURYLGHQXUVHVZLWKWKHODWHVWVFLHQWLÂżFDQGFOLQLFDOLQIRUPDWLRQ 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. Institute for Natural Resources (INR) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

EDMONTON, AB

RED DEER, AB

Wed., Nov. 1, 2017 8:30 AM to 3:30 PM Radisson Hotel 4520 76th Avenue Edmonton, AB

Thu., Nov. 2, 2017 8:30 AM to 3:30 PM Radisson Hotel 6500 67th Street Red Deer, AB

CALGARY, AB

Fri., Nov. 3, 2017 8:30 AM to 3:30 PM Executive Royal Inn 2828 23rd Street NE Calgary, AB

ACCREDITATION INFORMATION (cont'd) PHARMACISTS & PHARMACY TECHNICIANS

 $OEHUWDOLFHQVHGSKDUPDFLVWVVXFFHVVIXOO\ÂżQLVKLQJWKLVFRXUVHZLOOUHFHLYHFRXUVH FRPSOHWLRQFHUWLÂżFDWHV%LRPHGLVDQDFFUHGLWHGSURYLGHUWKURXJKWKH$PHULFDQ&RXQcil on Pharmaceutical Education. The ACPE universal activity numbers (UAN) are 0212-9999-17-002-L01-P and 0212-9999-17-002-L01-T. This is a knowledge-based CPE activity.

DIETITIANS

CPE Accredited

Biomed, under Provider Number BI001, is a Continuing Professional Education (CPE) Provider Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RD’s) and dietetic technicians, registered (DTR’s) will receive 6 hours worth of continuing professional education units (CPEU’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. This course has Activity Number 126805 and Suggested Learning Codes: 4000, 4040, 4190, 5100.

SOCIAL WORKERS

This activity is co-provided with INR. Social Workers completing this program will receive FRXUVHFRPSOHWLRQFHUWLÂżFDWHV$SSOLFDWLRQIRUDSSURYDORIWKLVFRXUVHKDVEHHQPDGHWRWKH$6:% for 6 hours of credit. This program is approved by the National Association of Social Workers (Provider #886502971-0) for 6 Social Work continuing education contact hours.

PSYCHOLOGISTS

Biomed General is approved by the Canadian Psychological Association to offer continuing education for psychologists. Biomed General maintains responsibility for the program.

For all inquiries, please contact customer service at 1-877-246-6336 or (925) 602-6140.

 REGISTRATION FORM 

Please return form to: Biomed Ste. 877 101-1001 W. Broadway Vancouver, B.C., V6H 4E4 TOLL-FREE: 1-877-246-6336 TEL: (925) 602-6140 Š FAX: (925) 687-0860

(This registration form may be copied.)

Wed., Nov. 1, 2017 (Edmonton, AB) Thu., Nov. 2, 2017 (Red Deer, AB) Fri., Nov. 3, 2017 (Calgary, AB)

Wed., Oct. 18, 2017 (Edmonton, AB) Thu., Oct. 19, 2017 (Red Deer, AB) Fri., Oct. 20, 2017 (Calgary, AB)

REGISTRATION INFORMATION

Please print:

Name: Profession: Home Address: Professional License #: City: State: Zip: Lic. Exp. Date: Home Phone: ( ) Work Phone: ( ) Employer: E-Mail: QHHGHGIRUFRQÂżUPDWLRQ UHFHLSW

Please enclose full payment with registration form. Check method of payment. Cheque for $109.00 (CANADIAN) (Make payable to Biomed General) Charge the equivalent of $109.00 (CANADIAN) to my

Visa

MasterCard

American ExpressÂŽ

DiscoverÂŽ

Most credit-card charges will be processed in Canadian dollars. Some charges will be in U.S. dollars at the prevailing exchange rate.

Card Number: Signature:

(enter all raised numbers)

Exp. Date:

CVV:

(Card Security Code)

3OHDVHSURYLGHDQHPDLODGGUHVVDERYHWRUHFHLYHDFRQÂżUPDWLRQDQGGLUHFWLRQVWRWKHPHHWLQJVLWH

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. A $15.00 fee ZLOOEHFKDUJHGIRUWKHLVVXDQFHRIDGXSOLFDWHFHUWLÂżFDWH)HHVDUH subject change without notice. The rate of exchange used will be the one prevailing at the time of the transaction.

Š Biomed, 2017, CODE: MFB-AB

Please check course date:

Hospital News 2017 July Edition  

Focus: Cardiovascular Care, Respirology, Diabetes and Complementary Health

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