Special: Canadian Society of Hospital Pharmacists Inside: From the CEO’s Desk | Evidence Matters | Safe Medication | Nursing Pulse
June 2018 Edition
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Contents June 2018 Edition
IN THIS ISSUE:
Hospital Supply Chain Network conference
16 ▲ Cover story: Transforming health care
▲ HIV resistance testing
8 ▲ Long–term care
COLUMNS Editor’s Note ....................4 In brief .............................6 From the CEO’s desk .....18 Evidence matters ...........56 Ethics .............................61 Nursing pulse ................63
▲ Diagnostic tool delivers personalized care
Special Focus: Canadian Societyy of Hospital Pharmacistss
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Women are important to the advancement of science,
let’s not hold them back
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By Paula Rochon and Paula Harvey t is abundantly clear that women bring a valuable lens to research. A diversity of opinions and perspectives leads to the questioning of dated assumptions and methodologies. For a field to progress, it needs to evolve. In the world of science, research that is led by women adds to the diversity of perspectives. In the most recent edition of the Canadian Medical Association Journal (CMAJ) there is an important study that demonstrates that the sex of a grant applicant impacts their funding success rate, even when factors related to scientific quality are considered. Female applicants were less likely than their male counterparts to be funded. Women are increasingly entering the scientific field, yet women continue to be under-represented in senior level positions. In medicine, more than 50 per cent of medical students are women. Yet at the senior research levels, few are women. This is more than a pipeline issue.
Success in science relates, in part, to the individual’s ability to obtain grant funding. Ability to gain funding is influenced by the applicant’s ability to demonstrate productivity. This includes previous successful grant funding and publishing in high impact journals. Unfortunately, lower funding success becomes a self-fulfilling prophecy for many. Success at obtaining research funding is a central pre-requisite towards increasing the representation of women in senior level positions within medical science. Subtle and important differences in funding scores can make a big difference to the result. Funding from Canadian Institutes of Health Research (CIHR) is very competitive. In the recent competition the overall success rate was less than 20 per cent. A small difference on the rating scale (from 0 to 4.9) can move a grant from the un-fundable to the fundable range. Funded research protocols provide the blueprint for the results that are eventually produced. Continued on page 7
Paula Rochon is Vice President, Research at Women’s College Hospital, Senior Scientist at Women’s College Research Institute and Retired Teachers of Ontario/ERO Chair in Geriatric Medicine, University of Toronto. Paula Harvey is Physician-in-Chief and F.M. Hill Chair in Academic Women’s Medicine, Women’s College Hospital and Scientist at Women’s College Research Institute
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Monthly Focus: Cardiovascular Care/Respirology/Diabetes/ Complementary Health: Developments in the prevention and treatment of vascular disease, including cardiac surgery,diagnostic and interventional procedures. Advances in treatment for various respiratory disorders, including asthma and allergies. Prevention, treatment and long-term management of diabetes and other endocrine disorders.
Monthly Focus: Paediatrics/Ambulatory Care/Neurology/ Hospital-based Social Work: Paediatric 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.
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Researchers combine wearable technology and AI
to predict the onset of health problems team of Waterloo researchers found that applying artificial intelligence to the right combination of data retrieved from wearable technology may detect whether your health is failing. The study, which involved researchers from Waterloo’s Faculties of Applied Health Sciences and Engineering, found that the data from wearable sensors and artificial intelligence that assesses changes in aerobic responses could one day predict whether a person is experiencing the onset of a respiratory or cardiovascular disease.
APPLYING ARTIFICIAL INTELLIGENCE TO THE RIGHT COMBINATION OF DATA RETRIEVED FROM WEARABLE TECHNOLOGY MAY DETECT WHETHER YOUR HEALTH IS FAILING “The onset of a lot of chronic diseases, including type 2 diabetes and chronic obstructive pulmonary disease, has a direct impact on our aerobic fitness,” says Thomas Beltrame, who led the research while at the University of Waterloo, and is now at the Institute of Computing in University of Campinas in Brazil. “In the near future, we believe it will be possible to continuously check your health, even before you realize that you need medical help.” www.hospitalnews.com
The study monitored active, healthy men in their twenties who wore a shirt for four days that incorporated sensors for heart rate, breathing and acceleration. They then compared the readings with laboratory responses and found that it was possible to accurately predict health-related benchmarks during daily activities using only the smart shirt. “The research found a way to process biological signals and generate a meaningful single number to track fitness,” says Richard Hughson, co-author and kinesiology professor at the Schlegel-University of Waterloo Research Institute for Aging. Beltrame and Hughson co-authored the study with Alexander Wong, Canada Research Chair in artificial intelligence and medical imaging and an engineering professor at Waterloo. He is affiliated with both the Waterloo Artificial Intelligence Institute and the Schlegel-University of Waterloo Research Institute for Aging. Robert Amelard, of the Schlegel-University of Waterloo Research Institute for Aging, is also a co-author. The study appears in the Journal of Applied Physiology.
“This multi-disciplinary research is a great example of how artificial intelligence can be a potential game-changer for healthcare by turning data into predictive knowledge to help healthcare professionals better understand an individual’s health,” says Wong. “It can have a significant impact on improving quality of life and well-being.”
Carré Technologies developed the smart shirts, called Hexoskin, used in the research. The team plans to test these systems on mixed ages and genders, and people with health issues to see how people might wear the sensors to gauge whether their health is H failing. ■
This article was provided by the University of Waterloo.
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more than doubles the risk of developing Type 2 diabetes A A
No link between HPV vaccination and risk of autoimmune disorders
dults in Ontario who live in food-insecure households had more than twice the risk of developing Type 2 diabetes, compared to those with food security, according to a new study from the Institute for Clinical Evaluative Sciences (ICES). Household food insecurity is described as uncertain, insufficient, or inadequate food access, availability, and utilization due to limited financial resources, and the compromised eating patterns and food consumption that may result. The study published in the journal PLOS ONE, used data from nearly 5,000 Ontario adult respondents to the 2004 Canadian Community Health Survey and linked it to health adminis-
trative data housed at ICES. “Our study illustrates the importance of addressing poverty when designing policies and programs to reduce the population-wide growth of Type 2 diabetes,” says Dr. Laura Rosella, adjunct scientist and site director at ICES UofT and assistant professor at the Dalla Lana School of Public Health at the University of Toronto. Type 2 diabetes is one of the most common chronic conditions in Canada. More than 11 million Canadians live with diabetes or pre-diabetes, a climb in prevalence of 72 per cent in 10 years. The number of Canadians living with Type 2 diabetes is expected to rise to 13.9 million (33 per cent of Canadians) by 2026. “Our findings indicate that food
insecurity is independently associated with increased diabetes risk, even after we adjusted for a broad set of other factors that have also been linked to the development of diabetes like obesity, smoking and alcohol use, which suggests that food insecurity should be considered a stand-alone risk factor,” adds Rosella. Food insecurity has been identified as a significant social and health problem in Canada. In 2004, it was estimated that 9.2 per cent of Canadian households were food insecure. The most recent estimate from 2014 (excluding two provinces and one territory that opted not to measure food insecurity in 2014) indicates that this number has risen to 12 per cent, repreH senting 3.2 million Canadians. ■
new study in CMAJ (Canadian Medical Association Journal) found no increased risk of autoimmune disorders in girls who received quadrivalent human papillomavirus (HPV4) vaccination, adding to the body of evidence for the safety of the vaccine. Human papillomavirus is the most common sexually transmitted disease worldwide, affecting 50–75 per cent of sexually active people. The HPV4 vaccine is effective at protecting against 90 per cent of the strains that cause cervical and anal cancer. Despite studies showing safety of the vaccine, there have been concerns about a possible link to autoimmune disorders. Continued on page 7
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Women and science
Continued from page 6
“Despite demonstrated effectiveness in real-world settings, concerns continue to persist regarding the safety of the HPV4 vaccine. In light of these concerns, we wanted to study the HPV4 vaccination since it was being offered free to all grade eight girls in Ontario through school-based clinics,” says Dr. Jeffrey Kwong, a study author and a senior scientist at the Institute for Clinical Evaluative Sciences (ICES) and at Public Health Ontario. To determine whether the HPV4 vaccination triggered autoimmune conditions such as lupus, rheumatoid
arthritis, type 1 diabetes and multiple sclerosis, researchers looked at data on 290,939 girls aged 12 to 17 years in Ontario who were eligible for vaccination between 2007 and 2013. Of the total 180,819 girls who received the HPV4 (Gardasil and Merck) vaccination in school-based clinics, there were 681 diagnosed cases of autoimmune disorders between one week and two months after vaccination. This rate is consistent with the general rate of diagnosed cases in this age group. “These findings add to the body of evidence on the safety of the HPV4
vaccine and should reassure parents and health care providers,” says Dr. Linda Lévesque, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario. The study was funded by the Ontario Ministry of Health and Long-Term Care, Drug Innovation Fund and the Canadian Institutes of Health Research (CIHR). “Quadrivalent human papillomavirus vaccination in girls and the risk of autoimmune disorders: the Ontario Grade 8 HPV Vaccine Cohort Study” H was published May 28, 2018. ■
Mothers more likely to stay in substance abuse treatment than pregnant women ntegrated treatment programs are doing a good job in engaging mothers who use substances in treatment and keeping them there. This study, Healthy Mothers, Healthy Families comes on the heels of the Motherisk Commission report released in February, which recommended, among other things, that there should be more support for “family-inclusive substance use treatment programs.” More than one third of all people who receive treatment for substance use and addictions are women – and more than half have children, or are pregnant. Many women also have experienced trauma in their lives and other barriers to substance use treatment. The four-year study, funded by CIHR (Canadian Institutes of Health Research) and the Ontario Ministry of Health and Long-Term Care,
looks at models of service delivery for pregnant and parenting women with problematic substance use, describing the types of services and collaborations that support the well-being of mothers and their children. “Ontario has the largest number of integrated programs in Canada,” says the study’s co-principal investigator Karen Milligan, a psychology professor at Ryerson University’s Faculty of Arts. “We are in a leadership position to evaluate the overall impact of these programs on treating pregnant and parenting mothers with problematic substance use.” The team found that older mothers tended to stay, on average, more than 11 days longer compared to younger mothers and pregnant women. Staying longer in treatment is associated with better outcomes (less substance use, better health, etc.). Mothers who were not mandated by the court system to undergo treat-
ment tended to visit their counsellor more often. In addition, those attending integrated treatment programs perceived their care more positively than those in standard programs. The team also found that the integrated programs, although successful in developing partnerships with different service providers, ran into barriers when the funding sources of these providers came from a myriad of government ministries, many of whom have different mandates and different understandings of how to address substance use problems. Finally, the researchers found that integrated programs had more limited partnerships with prenatal services (i.e. birthing centres/hospitals) or some physician-based services (i.e. medication-assisted treatment). Milligan says that that the key ingredient in these programs is relaH tionships. ■
Continued from page 4 Research led by women is more likely to consider sex and gender differences, and the inclusion of a sex and gender-lens leads to more comprehensive, inclusive and accurate scientific outcomes. Ensuring that information is available about both women and men in research studies means that this information can be tailored during the resultant care. Inclusion of sex and gender in all research improves science, paves the way to personalized medicine and ultimately improves all human health – not just the health of women and girls. This CMAJ article illustrates the impact of gender bias on grant funding decisions. We have often both been on peer review panels where women are in the minority. Peer reviewers may not even be aware of their bias. This study adds data to inform the importance of providing training to reduce unconscious bias on peer review panels. Documenting and sharing these data on funding results for women and men is an important first step. The potential bias towards women at the peer-review level, where funding decisions are made, may contribute to fewer women continuing in science. Until this is remedied, we are unlikely to witness a greater number of women in medical science leadership positions. We are aware of only one research institute nationally where there are more female than male scientists – that is Women’s College Research Institute in Toronto – as such, H there is much yet to be done. ■
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HIV resistance testing helps improve local and global health outcomes By Caroline Dobuzinskis hen a person is able to consistently stay on a course of HIV treatment that works effectively, their quality of life improves and their viral load becomes undetectable, meaning they cannot transmit the HIV virus to others. These concepts form the Treatment as Prevention® (TasP®) strategy, pioneered at the BC Centre for Excellence in HIV/AIDS (BC-CfE) in Vancouver.
THE TECHNOLOGIES WE ARE USING CAN HAVE AN ALMOST IMMEDIATE IMPACT ON THE HEALTH OF PEOPLE BEING TREATED FOR HIV
TasP® has the goal of reaching people living with HIV through early testing and treatment in order to improve their overall health while reducing transmission of the disease. It forms the basis of the United Nations’ Sustainable Development Goal and the UNAIDS 90-90-90 target to end AIDS by 2030. To achieve the 90-9090 target globally means diagnosing 90 per cent of people living with HIV, treating 90 per cent of those diagnosed, and achieving viral suppression of HIV in 90 per cent of those treated. Personalized medicine is an important piece of the TasP® strategy. On a daily basis, the BC-CfE conducts genome analysis of HIV virus samples from across the province, across Canada (except Quebec) and many places around the world. In British Columbia, HIV genomic analysis forms part of the standard of care when an individual has a detectable HIV viral load. The process, called resistance testing, allows for the identification of variants
A phylogenetic tree for the HIV virus. of the virus that are resistant to current HIV therapies. Those instances, due to virus mutations, are communicated to physicians to inform treatment decisions for the patient. “The technologies we are using can have an almost immediate impact on the health of people being treated for HIV, as resistance testing results are quickly reported to doctors to help better tailor treatment,” says Dr. Chanson Brumme, BC-CfE Research Scientist and Interim Director of the Laboratory Program. “On the laboratory side, we are aiming to continually improve HIV drug-resistance testing, real-time drug resistance surveillance and methods for personalizing treatment of HIV.” The advancements in personalized medicine for HIV contrast with the
early days of the disease, when more than 50 per cent of patients were responding poorly to initial therapies that were part of a one-size-fits-all approach. In addition to providing a direct benefit to patients’ therapy, resistance testing produces vast amounts of genetic data that, when put together, can yield additional insights. Studying a large collection of genomic data has improved our understanding of how the HIV virus evolves and how the disease can be better treated with existing drug therapies. The BC-CfE Laboratory Program mines the collection of HIV genetic sequence data for clues on how HIV is spread. Through this secondary use of data, BC-CfE scientists can identify groups of viruses in “family trees” with
similar genetic characteristics. Studying HIV in this way – called phylogenetics – can establish networks of HIV and help inform the BC-CfE on how to prevent new cases. The project is supported by Genome BC, Genome Canada, Genome Quebec, the Public Health Agency of Canada and the Canadian Institutes of Health Research. “When a cluster of HIV sequences from a number of infections have a high degree of genetic similarity, they are likely to be related by one or more recent transmission events. This information is useful for engaging individuals in treatment and care,” says Dr. Jeff Joy, BC-CfE Research Scientist. Since 2014, the BC-CfE has conducted similar analyses of hepatitis C virus in instances of drug therapy failure. This testing category forms part of the strategy for Targeted Disease Elimination® to address another major health burden of our time. In B.C., there are approximately 80,000 people living with hepatitis C. Since March of this year, hepatitis C treatment has been accessible to any British Columbian living with chronic hepatitis C as covered through PharmaCare. Globally, technologies developed at the BC-CfE Laboratory Program have expanded access to improved personalized medicine in resource-limited settings. The BC-CfE shares protocols with labs around the world and often hosts visiting scientists and technicians for training in drug resistance testing. In addition, the BC-CfE created an innovative software tool for HIV genomic analysis: RECall is offered free-of-charge and utilized in over 100 laboratories across Europe, Sub-Saharan Africa and South America. RECall automatically processes DNA sequences obtained from lab samples, significantly cutting down on workload and errors, allowing for more personalized HIV therapies and bringing faster testing results to individuals H living with HIV. ■
Caroline Dobuzinskis is the Communications Coordinator, BC Centre for Excellence in HIV/AIDS. 8 HOSPITAL NEWS JUNE 2018
Registered Nurses save lives. But only if weâ€™re there. Why is Ontario losing RNs?
The healing power of
philanthropy By Suzette Strong t is said that extraordinary patient care is both an art and a science. At Markham Stouffville Hospital (MSH) we see examples of that each and every day. While some visits are straightforward, others can be much more complicated. The primary goal always remains the same – getting our patients healthy and keeping them healthy. The relationship between the patient and their clinician is the ‘art’ and of the utmost importance when it comes to an extraordinary patient experience. Health care is an industry focused on people; similarly, fundraising is a high-touch business about human interaction rooted in trust and respect. People give to people. Bringing these themes together is the primary purpose of MSH Foundation’s recently launched Grateful Patient Program because we know that a positive experience drives a person’s decision to give. When people feel gratitude, they often feel the need to reciprocate. As its name suggests, our Grateful Patient Program is an initiative that provides our patients with a meaningful way to express their gratitude to their caregivers including physicians, midwives and nurses. It gives our patients and their families the opportunity to express their appreciation and give back to support other patients through the course of their healthcare journey. John Gibson is a grateful patient who feels passionate about giving back. “I had a stroke and lost my eyesight. I woke up totally blind one morning. My wife drove me to Markham Stouffville Hospital where I met Dr. Jeff Martow, an ophthalmologist. He worked very closely with me and thankfully helped recover most of my
Dr. Mateya Trinkaus, Oncologist at MSH, meets with a patient in her office. Dr. Trinkaus knows the value of engaging patients in philanthropy and is a strong supporter of the hospital foundation. eyesight,” says Gibson. “ We believe in the fabulous care we get from the doctors at MSH. Giving back to our hospital is the most enriching and fulfilling investment a person can make – I truly believe that.” At the MSH Foundation, we believe that expressing gratitude by making donations is a very tangible and meaningful way for patients and their families to give back. We also know that expressions of gratitude, such as those made by John Gibson, are linked to an increased ability to cope with stress, a stronger immune function, quicker re-
covery from illness, lower blood pressure, increased feelings of connectedness which improves relationships and well-being, greater joy, optimism and increased generosity and compassion. It has been said that gratitude unlocks the fullness of life. The fundamental principle behind this program is that compassionate care inspires generous giving. The Foundation is teaming up with MSH medical leaders, department chiefs, surgeons, cardiologists and oncologists to raise awareness about the importance of building a culture of gratitude
across the entire organization. Where patients show an interest in expressing their appreciation and demonstrating their gratitude to their caregiver and the MSH Foundation team works closely with the family to support their philanthropic needs by facilitating a donation – it’s a very direct and concrete way to show caregivers you appreciate them. We expect that this program will elevate the relationship between patient and caregiver to new heights, and help to extend the happiness of our grateful patients beyond their recovery. According to Dr. Mateya Trinkaus, Oncologist at MSH, “It is a privilege for me to be part of a patient’s care journey. I am humbled when my patients and their families want to give back and acknowledge the high-quality and compassionate care we provide in our cancer clinic during what is often the most difficult, and vulnerable times in their lives. For me, as a physician, it is an honour to accept this expression of gratitude and help bring closure to a challenging situation, or make something good out of something bad, particularly when a family member passes away.” Giving back makes people happy and happiness is linked to good health. There is no question that working together we are stronger, and ultimately more successful. As fundraisers, we owe it to patients and donors to make their giving as personal and meaningful to them as possible. Healthcare philanthropy represents the second largest source of funding for Ontario hospitals. More than ever before, hospitals rely on their foundation partners to raise funds to support life-saving equipment, cutting-edge medical technologies and strategic priorities that enable the growth and H innovation at their hospitals. ■
Suzette Strong is the CEO of the Markham Stouffville Hospital Foundation. 10 HOSPITAL NEWS JUNE 2018
KEEPING HOSPITALS SAFE. FIGHTING CANCER. Cobalt-60 from Bruce Power’s reactors helps sterilize 40% of the world’s single-use medical devices, and powers the Gamma Knife, which helps cure brain cancer.
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NEWS Dr. Xiaowei Song, a Fraser Health neuroimaging and aging brain health expert, stands in the Simon Fraser University NeuroTech and ImageTech Labs in B.C.â€™s Surrey Memorial Hospital.
Diagnostic tool delivers personalized frailty prevention to seniors By Elaine Oâ€™Connor
12 HOSPITAL NEWS JUNE 2018
CURRENTLY, HEALTH PRACTITIONERS ASSESS FRAILTY WITH A FEW INDICATORS THROUGH PAPER CHARTING. THE NEW ELECTRONIC FRAILTY INDEX TRACKS DOZENS OF INDICATORS AND QUICKLY RECALCULATES AS HEALTH CONDITIONS CHANGE. BENEFITS FOR CLINICIANS INCLUDE TIME SAVINGS, IMPROVED DIAGNOSTIC PRECISION AND THE ABILITY TO DO MORE PREVENTATIVE CARE AND TAILORED WELLNESS COACHING WITH VULNERABLE SENIOR PATIENTS BEFORE FRAILTY SETS IN, BECAUSE WHILE IT IS NOT REVERSIBLE, ITS ONSET CAN BE DELAYED
he future of seniors’ health care is being trialed in British Columbia, where Fraser Health Authority researchers are testing predictive technology to help seniors maintain their health as they age. The goal is to harness the power of personalized medicine to provide personalized frailty prevention plans to patients. The health authority won a $1.38 million grant from the Canadian Institute of Health Research (CIHR) last year to test this new seniors’ frailty identification technology – an electronic comprehensive geriatric assessment tool (eFI-CGA for short). This algorithm is embedded in electronic medical records (EMR) so physicians and care providers can automatically calculate a patient frailty index in the moment and over time as part of routine care. It enables clinicians to intervene to lower a senior’s frailty index if it begins to rise, prescribing tailored health plans to help aging patients maintain bone density, muscle tone, nutrition, etc.
to protect them from fractures, falls and nutrient deficiencies. With this knowledge, care providers then connect patients with the external supports and community resources they need to improve their initial signs of frailty. The aim is to prevent or delay the onset of frailty, enabling seniors to live healthier, longer, in their own homes and communities, rather than in acute care or residential facilities. Currently, health practitioners assess frailty with a few indicators through paper charting. The new electronic frailty index tracks dozens of indicators and quickly recalculates as health conditions change. Benefits for clinicians include time savings, improved diagnostic precision and the ability to do more preventative care and tailored wellness coaching with vulnerable senior patients before frailty sets in, because while it is not reversible, its onset can be delayed. Clinical scientist Dr. Xiaowei Song received the four-year award as the principal investigator along with Dr. Kenneth Rockwood, a world leader
in frailty research from Dalhousie University, Fraser Health’s Regional Medical Director Dr. Grace Park and Annette Garm, Executive Leader of the health authority’s Community Actions and Resources Empowering Seniors project (CARES). The frailty index, Dr. Song explains, “can act like a canary in a coal mine to tell us in advance that something could go wrong with their health.” “We have an aging society,” continues the neuroimaging and aging brain health expert from the NeuroTech and ImageTech Labs at Surrey Memorial Hospital. “We will have more people with frailty using hospital beds and acute health care resources. So if we can help them manage frailty, we can care for them with other services.” The eFI-CGA tool was developed by the team during foundational work in the CARES project, which began as a pilot project with area seniors in 2015, assessing their frailty and working with them for a year on improving their scores through well-
ness plans and lifestyle coaching from Self-Management BC. Annette Garm says the eFI-CGA is the first of its kind in the province and it gives physicians a unique advantage when caring for seniors. “Knowing and tracking a patient’s frailty index will support better assessment and management over time,” she says, “to prevent the descent of seniors into frailty.” The research team also included Fraser Health’s Samar Hejazi, Dr. Robert McDermid, Dr. Sonia Singh, Dr. Ryan D’Arcy, and Dr. Ronald Kelly, plus patient partner Joyce Sandercock and Dalhousie University’s Dr. Olga Theou. Dr. Song and an interdisciplinary team, including Surrey Memorial’s Dr. Ryan D’Arcy, also won a $15,000 award from the Michael Smith Foundation for Health Research to support early frailty assessment at home. The funding will support early development of wearable frailty assessment technology to allow patients themselves better monitor changes in their frailty and work on prevention with H their doctors. ■
Elaine O’Connor is a Senior Consultant, Communications at Fraser Health.
JUNE 2018 HOSPITAL NEWS 13
Genomics and precision health:
Transforming health care Since the first human genome was sequenced in the early 2000s, genomics – the science that aims to decipher and understand the entire genetic information of an organism – has had immeasurable impacts in the health sector. Genomics is now driving a revolution in precision health – an approach that is increasingly employed in health-care settings and stands to improve the lives of millions of Canadians. By Marc LePage or generations in Newfoundland and Labrador, seemingly healthy young men were struck by a mysterious affliction that would appear suddenly and kill them in their 20s and 30s. They would, quite literally and inexplicably, drop dead of sudden cardiac arrest. This remarkable phenomenon prompted a team at Memorial University in St. John’s to investigate a possible genetic explanation for what had been dubbed colloquially a “family curse.” With support from Genome Canada and Genome Atlantic, researchers identified and profiled affected families and, in February 2008, published the news that they had isolated the gene responsible for arrhythmogenic right ventricular cardiomyopathy (ARVC). Today, a simple blood test can diagnose ARVC and patients with the genetic mutation are preventively implanted with a defibrillator. To date, more than 160 people in Newfoundland and Labrador have been successfully treated as a result of this genetic testing. Other ARVC patients have also been fitted with defibrillators in mainland Canada, the United States,
14 HOSPITAL NEWS JUNE 2018
Denmark, Germany, Spain, Norway, and in other countries around the globe, preventing countless heart attacks and adding some 30+ years to the lifespan of individuals who receive the device. This is just one example of how medicine is being transformed by genomics and precision health. Precision health is an approach that enables diagnosis and treatment to be tailored based on a patient’s unique genetic makeup. Given that genetic differences can explain why some people respond well to certain treatments while others do not, doing this systematically in health care can be transformative. As anyone knows who has watched a television medical drama – from Marcus Welby M.D. to House – the practice of medicine is usually a variation on the classic detective procedural. A patient presents mysterious symptoms, the doctor evaluates the evidence against suspected culprits and a hopeful course of action is adopted. Now, genomics – in combination with big data, predictive analytics and other areas of cutting-edge science and technology – is enabling trained professionals to significantly telescope
PRECISION HEALTH IS AN APPROACH THAT ENABLES DIAGNOSIS AND TREATMENT TO BE TAILORED BASED ON A PATIENT’S UNIQUE GENETIC MAKEUP the process of elimination, solving diagnostic mysteries at the genetic level with far greater speed and efficiency, while producing more accurate answers. Internationally, there is a sense of excitement about what this means for the future of medicine. The government of Canada, through funding for Genome Canada, has been at the forefront of what is now a collegial global competition to harness the transformative power of genomics toward more efficient, effective and economical health care. To this end, the federal government, Genome Canada, and partners announced a $255 million investment
in genomics and precision health research this January, bringing new hope for Canadians living with cancer, cystic fibrosis, juvenile arthritis, childhood asthma and other diseases. The results of Genome Canada’s 2017 Genomics and Precision Health competition, announced by federal Minister of Science Kirsty Duncan, includes a $162 million investment through Genome Canada, the Canadian Institutes of Health Research (CIHR) and co-funding provinces and partners in 15 genomics and precision health projects across Canada, in addition to $93 million for 10 genomics technology platforms across Canada. One of these projects is UCAN CURE: Precision decisions for childhood arthritis, led by Drs. Rae Yeung (The Hospital for Sick Children) and Susanne Benseler (University of Calgary). More than 24,000 children in Canada live with painful, chronic arthritis. With the help of powerful drugs called biologics, doctors can dramatically reduce joint inflammation and pain and prevent long-term joint damage. But first, doctors must determine – using the first genomics-based, lowcost biomarker blood test – who needs biologics, which biologic will work best www.hospitalnews.com
Single Mendelian genetic rare diseases are particularly well suited to precision health approaches, which can dramatically reduce time to diagnosis and avoid patient harm in the form of invasive tests, futile therapies and treatment delays.
for an individual child, and when the biologic can be safely stopped. One of the children who may benefit from UCAN CURE attended the precision health announcement with Minister Duncan at SickKids in Toronto. Aida Kelf-Kowal is nine years old and was diagnosed at age five with juvenile idiopathic arthritis. She and her parents went through an overwhelming process of trial-and-error before finally finding a medication that put her arthritis into remission. UCAN CURE will reduce this diagnostic odyssey and help make sure kids like Aida receive the best and most appropriate medication available as quickly as possible. These breakthroughs require collaboration at the policy level so that innovations in genomic science and precision health are not stymied by the challenges of implementation. In October 2016, Genome Canada, the six regional Genome Centres and CIHR co-hosted a Genomics and Precision Health Forum in Toronto, where stakeholders, experts and opinion leaders from Canada and around the world compared notes on the implementation of genomics in their health-care systems. Among the valuable takeaways from the event was the consensus that the major challenges in bringing precision health to clinical settings are generally policy-related rather than technical.
The speed of genomic sequencing is now fast and cost is dropping — but major challenges exist around data sharing, privacy, infrastructure and other legal and ethical obstacles to implementation. We are working hard with public and private partners to overcome these challenges comprehensively and responsibly. That forum laid the groundwork for a precision health strategy in Canada with specific recommendations: • Develop a national vision for the implementation of genomics into the health-care system and start with a demonstration project in a targeted area to provide the foundation for precision health more broadly. • Incorporate a health technology assessment service in publicly funded research projects to ensure a harmonized and proactive pathway for the assessment of new technologies. • Establish national guidelines for the assessment and evaluation of genomic tests to support a harmonized and streamlined approach to the adoption of genomic tests by each province. • Develop and promote the adoption of national standards for the collection, aggregation, integration, storage and governance of data generated with public sector funds, in alignment with the standards ar-
ticulated by the Global Alliance for Genomics and Health. • Support the development of appropriate curriculum and tools for the education and training of students and health-care practitioners to ensure the comprehensive and equitable use of genomic tests in clinical care. • Consider how elements established by Canada’s Strategy for Patient-Oriented Research and related initiatives and platforms can be integrated into existing health-care delivery and research structures. • Develop a white paper to articulate the roles and responsibilities of each stakeholder involved in health-care system transformation and help strengthen the precision health research and delivery continuum. Genome Canada is contributing to a national effort on precision health in numerous ways, including spearheading a demonstration program focused on patients with rare genetic disease – a group of approximately one million Canadians, more than 50 per cent of whom are children. This initiative builds on several past and current projects and is designed to tackle questions of governance frameworks, data standards and more. Our focus on rare diseases will help develop the infrastructure, skills, experience and partnerships essential
for the implementation of a nationally harmonized program that leverages Canada’s burgeoning reputation as a global leader in pediatric precision health. Incidentally, Dr. Brendan Wren – one of Britain’s leading experts on the genomics of infectious and tropical diseases and a member of Genomics and Precision Health competition international peer review committee – said of Canada’s research excellence in the field, “If I were ill, particularly if I had a sick child, I would want to live in Canada rather than anywhere in the world.” The promise of precision health is a future where the best health care available meets personal needs with improved outcomes and strong economic growth for Canada. This country has the political will to drive innovation in health-care delivery, including an increasing focus at the provincial level, a thriving genomics research culture, an ethnically diverse population and a universal health care system that make us exceptionally well-placed to advance the precision health revolution. That vision will require leveraging our world-class knowledge and expertise, capitalizing on the unique assets of the Canadian health-care system and genomics enterprise, and ensuring genomic-based innovations can be effectively implemented for the benefit of H people here and the world over. ■
Marc LePage is President and CEO of Genome Canada. This article first appeared in Policy magazine, May 2018. www.hospitalnews.com
JUNE 2018 HOSPITAL NEWS 15
People milling about in the exhibitor area at the HSCN conference.
Hospital Supply Chain Network Conference By Pippa Wysong his year’s annual conference of the Healthcare Supply Chain Network (HSCN) was a hub of activity. While the conference programs were well attended, the exhibit hall was also a busy scene. Here, we present some highlights of what Hospital News learned there. First was a stunning display featuring a graphic artist from ThinkLink who casually chatted with attendees and then created graphic representations, on-the-spot, of how they responded to “How do you envision supply chain management in 10, 15, 20 years?” At the center of the piece, not surprisingly was the patient. The project was sponsored by Healthcare Insurance Reciprocal of Canada (HIROC) and a spokesperson noted that important themes that came up in responses from attendees
16 HOSPITAL NEWS JUNE 2018
TWO EXHIBITS AT THE HSCN SHOWED THAT BARCODES WILL BECOME MORE INTEGRAL PARTS OF HOSPITAL LIFE, AND WILL HELP WITH EVERYTHING FROM TRACKING ITEMS FROM THE LOADING DOCK TO DISPOSAL included: newer uses of technology, improving personal relationships and more opportunities for collaboration. HIROC is a non-profit healthcare liability insurer which was created in 1987 when 53 of Ontario’s hospitals and healthcare organizations came together to create a self-administered liability insurance plan. It has since grown to become Canada’s largest non-profit healthcare liability insurer, owned by its subscribers. Also spotted among the exhibits was a new bed, the ook snow All – a
new 3-in-1 hospital bed from umano medical. Generally, hospitals have separate beds for bariatric, med-surg and low height purposes, and may be stored if they are not needed by specific types of patient. But the ook snow All can be turned into any of those three – meaning it can continue to stay in use. On the market only since January, this bed has a width that can be adjusted. At its widest, it can support two people, often a desired feature with palliative patients and for birth-
ing, and has a 1,000 lb capacity. The height of the bed can be adjusted, with the lowest level being 10 inches/25.4 inches off the ground. It also has a built-in bed exit detection system to minimize falls and a built-in scale. If open shelving units don’t give you enough selection for storing items, ACART was showing off one of its new KanBan Systems. It is a portable, stainless steel unit that has both shelves and baskets. The walls of the baskets are pressure-fitted and can be adjusted to whatever size is needed. What was Staples, the office supply store, doing in a healthcare exhibit hall? Did you know Staples does $1.2-billion worth of business in North and South America just in the healthcare sector? $30-mil/year of that is with Canadian healthcare settings. A lot of it has nothing to do with paperclips or toner cartridges (though, that www.hospitalnews.com
NEWS What’s going on in the minds of people at the @HSCNetwork conference? An artist from @ ThinkLink took comments from attendees and putting them into a visual story. Patients are at the centre and people would like more collaboration. Sponsored by @HIROCGROUP is a part of it). Products supplied by the company include janitorial and cleaning supplies; antimicrobial keyboards and mice; medical carts, hospital and cafeteria furniture, hand sanitizer, and even some chemical products. Two exhibits at the HSCN showed that barcodes will become more integral parts of hospital life, and will help with everything from tracking items from the loading dock to disposal. Barcodes are symbols that can be scanned electronically using laser or camera-based systems, and are used to encode data such as product numbers, serial numbers and batch numbers. They play a key role in supply chains
(think grocers), providing an easy way to keep track of inventory, including how much there is and where it’s located. They can be put on everything from medications, surgical tools, packaged food items, catheters and even patient
bracelets. Barcodes can also help provide recall and expiration alerts, medication doses, and more. One exhibitor was Genesis Automation – a company that creates barcodes for specialized uses as well as wireless phone-sized readers that can read any
barcode. Another was GS1 (Global Standard) Canada which is part of a neutral, not-for-profit international organization helping set standards for barcodes and is working to get more healthcare settings on-board with imH plementing barcode systems. ■
Pippa Wysong is a freelane writer in Toronto.
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Healthcare in Canada: Where are the opportunities? By Mary Ackenhusen anadians need a wake-up call about the state of our health care system and the fact it will not sustain us into the future. With an aging population, soaring costs, outdated compensation models, and a history of lackluster investment in technology, we can no longer be complacent about that in which we once took so much pride. Multiple studies show that the growing cost of our health care system only produces average outcomes and our health care spending – which is about 40 per cent of the provincial budget in British Columbia – is squeezing funding for other important investments that we know are major contributors to population health: education, housing, social programs, economic investments, and infrastructure. In other words, the cost of maintaining the status quo in healthcare is slowly eroding virtually everything else we hold dear in this country. And yet, beyond Canada, there are systems that provide superior service at lower cost. Across virtually every comparison cited in a recent Commonwealth Fund study of OECD countries, the US is at the bottom – 11/11 – and Canada is usually 10/11. In 2016, we were ninth comparing cost, access and quality. I believe this is because our system today rewards volume of care, not quality, patient experience, or responsible stewardship. So care is being provided, but not necessarily in a way that we can hold on a pedestal of “best practice”. We are heavily invested in a health care system we cannot afford, and in many ways the system is resistant to change. We default too easily to acute and residential care because community alternatives are difficult to engage – even ones within our control. But change is possible – and essential. To bring our system to the 21st Century and deliver comprehensive
Mary Ackenhusen care for a growing population of older people – as well as an emerging population of tech-savvy younger people – we need new operating models, data-enabled care, and options for patient-led care facilitated through technology. We must advance big data platforms for personalized medicine, flexible diagnostics, and predictive medicine. Around the world, it is recognized that healthcare can be delivered more effectively and less expensively in the community so we must expedite our shift away from hospitals to comprehensive community-based care. Instead of investing in bricks and mortar, we can use our valuable (and scarce) resources to improve primary care homes and networks, create urgent care centres, and advance telehealth, with hospital care reserved for acute, episodic needs. Most importantly, as consumers, we must advocate and pay for what we want. Today, excellence is not rewarded and often quality, outcomes,
and patient satisfaction have nothing to do with how a physician is paid. We must compensate for value, not volume alone, and demand investment in innovation that will lead to new models of care and the best outcomes overall. All of this is within our reach. We can leverage the power and potential of the digital revolution starting with information systems that offer a single electronic patient record so that all providers in all locations have the same picture of the patient. With access to a common health record for all providers, we reduce redundancy, produce automated real-time data, and achieve better-informed, standardized care – and we empower patients by giving them access to their own information. The tools are already at our finger tips: The smart phone has become a portal to manage much of our lives so why not our health too? In other industries where consumers shift to a
leadership position, they call it “democratizing services” and it is our future in healthcare. It is one of many shifts that will allow us to maintain universal access at a reasonable cost, but it can offer us so much more in terms of quality outcomes: • patients “owning” their information and care; • predictive analytics that help alert patients and providers to events; • research that can be enhanced through more and better data; • mobile diagnostic and health monitoring devices that lead to quicker, better-informed decision-making. The next big software update for the iPhone will likely include a “Health Records” feature to allow users to view, manage and share their medical records. Certainly there are some concerns about privacy and data sharing, but if we want the benefits and outcomes badly enough, surely we can advocate for solutions on this front as well. This is about thinking bigger and focusing on the possibilities, rather than the barriers. It is time for public healthcare in Canada to capitalize on the many opportunities for superior care that have been proven out in other jurisdictions. As hard as it is for a monopolistic industry with a risk adverse culture to reinvent itself to meet modern healthcare demands, we have to start now – in fact we should have started yesterday. At Vancouver Coastal Health the change is underway: We are fostering innovation internally, primarily around digital technology and telehealth with support for pilots and commitment to scale-up where we experience early success. We are making a substantial shift to demonstrate – to our staff and to our business partners – that we are open for business and committed to finding solutions for a sustainable public healthcare system into the future. We see the opportuniH ties and we are ready to seize them. ■
Mary Ackenhusen is President and Chief Executive Officer of Vancouver Coastal Health. 18 HOSPITAL NEWS JUNE 2018
Canadian Society of Hospital Pharmacists
JUNE 2018 HOSPITAL NEWS 19
CANADIAN SOCIETY OF HOSPITAL PHARMACISTS
20 HOSPITAL NEWS JUNE 2018
CANADIAN SOCIETY OF HOSPITAL PHARMACISTS
Patient-centred Pharmacy Care
Myrella Roy, BScPhm, PharmD, FCCP Executive Director
Patrick Fitch, BSP, ACPR President
Welcome n behalf of the Board of the Canadian Society of Hospital Pharmacists (CSHP), we welcome this opportunity to collaborate with Hospital News in featuring hospital pharmacy practice. CSHP is the national voluntary organization of pharmacists committed to patient care through the advancement of safe, effective medication use in hospitals and other collaborative healthcare settings. Founded in 1947, CSHP is a member-driven organization that operates at several levels: national, provincial branches, local chapters, affiliated boards, committees, and task forces. In 1988, it established the CSHP Research and Education Foundation to raise funds in order to support research projects and targeted education programs undertaken by members of CSHP. It has also forged a strategic alliance with the Association des pharmaciens des établissements de santé du Québec, the hospital pharmacist association in Quebec. CSHP supports over 3100 pharmacist members and student pharmacist and pharmacy technician supporters through the following programs and services: • advocacy and external representation to other organizations and the federal government
• continuing professional development (conferences, webinars, etc.) and residency accreditation • information sharing in online forums and via a benchmarking report on hospital pharmacy services in Canada, a peer-reviewed journal, and bulletins • promotion of best practices via guidelines and the Excellence in Hospital Pharmacy program • facilitation of research with grants from the CSHP Research and Education Foundation • recognition of excellence with awards and honours In addition to holding a first university degree in pharmacy, a substantial number of pharmacists practising in hospitals and other collaborative healthcare settings have also pursued graduate formal training and studies or have completed a residency program, an additional year or two of experiential education that focuses on the application of therapeutic knowledge to patient care. Residency programs are accredited by the CSHP Canadian Pharmacy Residency Board to ensure quality in terms of both content and learning experience. In closing, we invite you to learn more about CSHP by visiting H www.cshp.pharmacy. ■
The Canadian Society of Hospital Pharmacists describes its vision for patient-centred pharmacy practice in its publication, Pharmacy Practice in Hospitals and Other Collaborative Healthcare Settings: Position Statements: patient-centred pharmacy practice respects and values the patient (and family) as a keypartner in decisions about healthcare. The care model is about getting to know the patient as a person, not a disease that needs to be treated. Listening to, understanding, and respecting the patient’s story about experiences and expectations that will affect the use of medicines are key components of the model. Patients should tell their story about medicines they are currently taking, or have recently taken, and any problems they had taking the medicine. It’s also important for the patient to tell the healthcare team what she realistically expects from the care provided. Pharmacists, and other healthcare professionals, consider this information when choosing which medicine, if any, the patient should take as part of the care plan.
JUNE 2018 HOSPITAL NEWS 21
CANADIAN SOCIETY OF HOSPITAL PHARMACISTS
Automation in Canada’s in-hospital pharmacies
espite the amount of focus on electronic health records today, manual and paper-based processes continue to play a significant role in Canadian hospital pharmacies. According to a recent survey conducted by Ricoh Canada involving over 220 respondents from 179 unique Canadian hospital pharmacies, 2/3rds
22 HOSPITAL NEWS JUNE 2018
of responding pharmacists stated that their hospital medication order entry processes still rely on paper. Computerized physician order entry (CPOE) projects, which would eliminate most paper based medication workflows, are still many years away for some health care providers, yet automation of medication order management processes is needed to-
day to keep up with demand, ensure patient safety, and meet regulatory requirements. For the great many, for whom budget or resource constraints make it impossible to take on a costly and complex CPOE migration today, the solution may be a hybrid paper-to-digital “bridge” that leverages existing in-hospital technologies and infra-
structure, mirrors existing processes, and can continue to play a role in a future CPOE migration. Ricoh’s Pharmacy order management solution is a relatively low-cost and lightweight workflow and communication tool that Canadian hospitals can deploy today to have a major impact on in-hospital pharmacy efficiency and patient safety.
CANADIAN SOCIETY OF HOSPITAL PHARMACISTS
Dedicated pharmacists improve patient safety aving a dedicated in-hospital pharmacist who can take the time to listen and educate has made a huge difference for William Knihnicki, a recent patient on 7th Medicine at St. Paul’s Hospital in Saskatoon. “When I came to the hospital, I truly believed I was taking too many drugs. I had no appetite and a lot of pain,” he says. “Having time to really talk to the pharmacist was helpful. She solved my appetite issue and (since then) they’ve even been able to take me off another drug, which is nice. I now understand what the drugs do and why I need to take them.” Experiences such as Knihnicki’s, where in-hospital pharmacists have the time to listen, dig deep into a medical history, answer patient questions, and work closely with their home pharmacy and physician, are becoming more common with the introduction of Connected Care Units (CCUs). CCUs are a system of care where care team members are better connected to one another and are responsible to each other to ensure that patients receive the safest, highest quality care possible. The care of each patient is overseen by a hospital-based physician who manages treatment and tests prescribed by specialists, and by a unit-based registered nurse (RN). The RN collaborates with the physician, specialists and other medical staff, including pharmacists, to assist with patient treatment. An Accountable Care Unit (ACU) follows the same model, but has some enhanced protocols that help ensure consistent care for more intensive medical conditions. The ACU model, now part of a larger Connected Care Strategy, was first implemented in Regina at Pasqua Hospital in 2016. Since that time, a number of ACUs have been established in Regina and Saskatoon. Lloydminster Hospital’s Third Flood Medical Unit launched the Connected Care model in January, while Battlefords Union Hospital in North Battleford designated the Acute Care Medical/Intensive
Care Unit as a Connected Care Unit in February. One of the most significant changes within Connected Care hospital units is to have care team members (attending physician, primary nurse, pharmacist, social worker, Client Patient Access Services, physical and occupational therapy, dietician, etc.) dedicated to and located on the unit. This allows for more meaningful and regular interactions with patients like William and with other health care providers while improving patient medication safety. Jeff Herbert was the first pharmacist in Saskatoon to participate in the ACU model of care, and the first Saskatchewan pharmacist to be Structured Interdisciplinary Bedside Rounds (SIBR®) certified. “Prior to the ACU, a pharmacist was responsible for providing care to 80-100 patients every day. All we could do was solve problems generated from the dispensary and complete as many admission medication reconciliations as possible. Working on the ACU is a dream as I finally get to practice the way I was educated in my undergraduate training and pharmacy residency. Being able to see and talk with all my patients on a daily basis empowers them to understand what’s actually going on with their medications during their hospitalization.” “The pharmacists on this unit now have more time to truly investigate patients’ care needs because the number of patients they are responsible for is significantly lower,” says Barb Evans, pharmacy manager for St. Paul’s and Royal University hospitals. “We have time to do our work like we have always wanted to.” Another major patient safety improvement for pharmacists on 7th Medicine involves discharge medication planning. “We now have time to focus on discharge planning and communication,” explained Evans. “We can make sure the patient, their pharmacy and their family physician are all aware of what drugs need to continue post-discharge and what drugs have
This article was submitted by the Saskatchewan Health Authority. www.hospitalnews.com
Janelle Bortis, one of the pharmacists on 7th Medicine at Saskatchewan Health Authority, meets with her patient, William Knihnicki, at his bedside. been stopped. This improves safety and can reduce readmissions.” Knihnicki credits his good experience to dedicated staff on the unit. “I feel so much better. Thank you.”
The Connected Care Strategy is a provincial initiative designed to improve emergency wait times and patient flow, and strengthen team-based care H in hospitals and in the community. ■
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CANADIAN SOCIETY OF HOSPITAL PHARMACISTS
Did you know? 1. Hospitals have pharmacies that are responsible for providing the medicines used throughout the hospital • Outpatient pharmacies in hospitals are not the same as hospital pharmacies. Hospital pharmacies take care of the patients in the hospital. • If your hospital has an outpatient pharmacy, that is not the hospital pharmacy. 2. The pharmacy team helps improve medication use • Hospital pharmacies have pharmacists, pharmacy technicians, and others who
work to help ensure that patients receive safe and effective medicines. They do more than dispense drugs! The pharmacy team works in close collaboration with other healthcare professionals to ensure the most appropriate care is being provided to patients. Together, they prevent and solve problems people might have in properly taking their medicines. There are almost 7 000 pharmacists working in hospitals in Canada, and roughly the same number of pharmacy technicians and assistants together. • They looks for trends in how drugs are being used in the hospital and
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what safety problems might be occurring. Their in-depth analysis helps the hospital to make improvements. 3. Pharmacists work with other healthcare professionals like nurses, doctors, and others on the patient care unit • Pharmacists are medication experts who review and assess a patient’s health information and medication history to ensure that any medications prescribed for the patient are needed, effective, and are safe to be administered. They create pharmacy care plans that are specific to what is best for the patient– that can mean switching medicines, starting new ones, or stopping some. And, they follow up to see how the patient is reacting to the drug – is she doing better with the drug or having side effects? • Patient care improves when a pharmacist is directly involved in the care of patients on the unit. There are better patient outcomes, decreased emergency department visits, decreased hospital re-admissions, decreased length of stay, decreased overall health-care costs, and fewer adverse drug reactions. • Pharmacists work in many areas of the hospital directly caring for patients – in emergency departments, inpatient care units, or outpatient clinics. Some pharmacists also provide care in the patient’s home. • Pharmacists teach other healthcare professionals about medicines: how the drugs work, how to prepare the drugs to give to patients, how to check if the patient is benefitting from the drug, and the significance
of drug interactions that might occur with other drugs the patient is taking, or how the patient’s medical condition could affect how the drug works for the patient. 4. Pharmacy technicians do more than count tablets • Pharmacy technicians are largely responsible for ensuring that the drugs prescribed for a patient are supplied correctly – the right medication, in the right formulation, at the right strength, in the right quantities. • They make sure that drugs are available in the patient care areas in case a patient needs immediate, urgent, or emergency care. • They listen to the patient (or her family) share information about the medicines the patient is taking. This information is recorded in the patient’s health record and is used by pharmacists and other prescribers to make decisions about how to best care for the patient. 5. The pharmacy team helps prepare patients to manage their medications at home • The pharmacy team reviews the list of medicines that the patient should be taking at home to make sure that it is correct and complete. They teach people how to use devices to take their medication (for example, by inhaler or by injection). They also help the patient create a plan to properly take their medicines after they are discharged from the hospital. This often involves communicating with the patient’s community pharmacist, home care nurse, or H physician. ■
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Do not use abbreviations:
Are we winning? et’s start with a pop quiz. Check out figure number one for an example of a record extracted from a patient’s progress notes as part of the best possible medication history:
es Canada’s “Do Not Use: List of Dangerous Abbreviations, Symbols and Dose Designations.” To support this adoption, we developed a stellar armamentarium of tools to help prescribers and front line staff reduce the risk for patient harm.
THE BEST TOOLS TO HELP
c) Type of Do Not Use abbreviation used d) Incidence of Do Not Use abbreviation use This information is available to leaders, managers and staff in user-friendly graphs and tables to monitor progress in a variety of formats. With this information at your fingertips, you can really focus on which “Do Not Use Abbreviations” to target.
Imagine you’re the prescriber using YOU KNOW YOUR ENEMY this information to write admission orWe at AHS have some handy tools ders. What will you prescribe? Choose that help remind us about our “Do Not the best answer: MONTHLY AWARENESS Use Abbreviations” list. A) Humalog 40 units at breakfast, 20 CALENDAR units at lunch, 60 units at dinner Make your campaign Visible. AUDIT TOOL AND AUDIT and Lantus 140 units at bedtime. Monthly Awareness Calendars are RESULTS TRACKING B) Humalog 44 units at breakfast, 24 available that create a strong visual At AHS, a monthly/quarterly comunits at lunch, 64 units at dinner presence in your area highlighting an puterized audit tool is used to capture and Lantus 144 units at bedtime. abbreviation of the month, which is up quantitative and qualitative informaC) Humalog 4 units at breakfast, 2 for eradication. Take a look at Figure tion including: Units at lunch, 6 units at dinner number three to see the kinds of calena) Prescriber Profession and Lantus 14 units at bedtime. dars we distributed around our sites. di b) Type of order We’ll get to the answer nswer of this pop quiz in a second.. But first, what needs to be stressed here is how hazardous a misinterpreted abbreviation n can be. This is a classicc example of what we call ll a “Do not Use Abbreviaation.” “U” can and does cause use serious and fatal medication ion errors. It can be interpreted eted as the letter U or can easilyy be misinterpreted as the number mber four (4) or even the number mber zero (0). Add a dash of illegible egible handwriting and that becomes comes a recipe for a major medication cation catastrophe. So, which order did d you choose? The admitting orders were actually written as Choice B above. Fortunately, a savvy pharmacist noticed the unusual dosing and requested clarification. The Alberta Health Services (AHS) policy adopted the Institute for Safe Medication PracticLeft: Figure 4: Poster; right: figure 3: Calendar
POSTERS ‘Do Not Use Abbreviation’ posters are available to be displayed in high traffic areas such as patient care areas and physician lounges. Figure number four shows the kinds of posters we’ve used at our different sites.
VIDEO MESSAGING AHS uses video message displays on patient care area information monitors. Whenever possible, we’ve displayed different messages about our “Do Not Use Abbreviations” list as quick reminders to physicians and other healthcare professionals as they’re checking in on patients.
GET YOUR TEAMS ON BOARD Spread the word. Rally the troops to your cause with targeted education sesprescribers, nurses and pharsions for prescribers macists. There are superb awareness educational aand resources available tto physicians. See tthis doctor’s video testimonial about te what almost hapw pened to him: pe https://www. youtube.com/ watch?v=npCvQtVmbAo&feaCv ture=youtu.be ture As corny as it A sounds, our grandfasoun thers were right when they said, “people do really support causnot re they support people es; th with ccauses.” We eradicated Polio in Canada in just 21 short years making it everyone’s by mak cause. Imagine what we can do together with “Do Not Use Abbreviations” if pick them up as our we all pic H cause. ■
This article was submitted by Celina Colegrave and Ken Wou, Alberta Health Services. 26 HOSPITAL NEWS JUNE 2018
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Diversion of opioids and other controlled medications in hospitals pioid-related deaths have been on the rise in Canada in recent years, resulting in leaders to call on action to address this crisis. The Joint Statement of Action to Address the Opioid Crisis outlines the many initiatives underway including improving prescribing through new guidelines, ensuring availability of antidotes to treat overdoses and supporting access to resources for practitioners and those affected by opioid use disorder. Recognizing that there has been minimal study of the safeguards surrounding the large supplies of opioids and controlled drugs in hospitals, the HumanEra research team based at North York General Hospital, along with the Institute of Safe Medication Practices Canada (ISMP) recently conducted a scoping review of the literature and an extraction of diversion data from Canadian database repositories. The findings thus far, together with direct observations of hospital practices around the medication use and peripheral processes, aim to identify specific vulnerabilities that may exist within the hospital environment and inform future interventions that may mitigate the identified risks. Publication of these findings is expected in 2018-2019. The Canadian Society of Hospital Pharmacists will make use of HumanEra’s research as they develop guidelines for preventing, identifying, and responding to opioid diversion in hospitals and other healthcare facilities. The guideline will update and build on previous guidance documents from Health Canada and will include input from many collaborators. To date, partners include Health Canada, HealthCareCAN, the Canadian Nurses Association, the Canadian Anesthesiologists’ Society, the Paramedic Association of Canada, the Canadian Association of Emergency Physicians, ISMP Canada, and several health professional regulatory bodies. Publication of the guidelines is expectH ed at the end of 2018. ■
This article was submitted by Sarah Jennings, Canadian Society of Hospital Pharmacists and Dorothy Tscheng, Pharmacist, Institute for Safe Medication Practices Canada (ISMP Canada). 28 HOSPITAL NEWS JUNE 2018
Members of BC Cancer’s Pharmacy Team in Vancouver.
Optimizing drug therapy for patients with cancer id you know that one in two Canadians are diagnosed with cancer at some point in their lives and that one in four Canadians die from cancer? So unfortunately, either we or someone we know and care about will be faced with the diagnosis of cancer. Medication therapy for cancer, although life-saving in some circumstances, can have significant side effects and drug interactions, to the extent that medication errors can lead to devastating outcomes for patients. Pharmacists, through their medication expertise can identify and resolve drug therapy problems, thus improving the intended outcomes with drug therapy, while minimizing side effects and drug interactions. At BC Cancer in Vancouver, pharmacists identify and resolve more than 20,000 medication-related problems every year. They do this by tapping into their in depth clinical knowledge about drug therapy, while asking such questions as: • Are the right types of medications being used for the diseases that the patient is experiencing or may be at risk for? • Are medications prescribed at the right doses, routes, frequencies, and durations? • Are there any potential or actual drug interactions between the prescribed cancer medications
AT BC CANCER IN VANCOUVER, PHARMACISTS IDENTIFY AND RESOLVE MORE THAN 20,000 MEDICATION-RELATED PROBLEMS EVERY YEAR and other medications and/or natural health products the patient is taking? • Can the patient’s medication therapy be simplified by discontinuing the medications that are no longer needed? • Is there anything the patient could do to minimize the risk of experiencing medication-related side effects or complications? • When should the patient contact the healthcare team to share potential concerns about cancer treatment? • Are there certain tools and resources to help patients learn more about their cancer and its treatment, and assist them with complying with their prescribed medication therapy? Without question, there are numerous health benefits to patients having their medications reviewed by a pharmacist in the cancer setting and otherwise. Wouldn’t it be great if every patient in the healthcare system could have access to a pharmacist for the purpose of a comprehensive medication review? This would have huge cost-saving impli-
cations, in addition to known health benefits. In addition to clinical interventions, pharmacists at BC Cancer are integral members of the healthcare team, who contribute to the development of cancer treatment protocols, pre-printed order forms, patient information handouts, drug information requests, research initiatives, as well as many other patient-focused activities. An area of research that has created quite a lot of interest at BC Cancer is its Personalized Oncogenomics Program (POG), which is a collaborative clinical research initiative that evaluates the impact of genomic sequencing on treatment planning for BC patients with advanced cancers. By understanding the genomic changes that contribute to cancer and its behaviour, cancer treatment can be more targeted to potentially achieve better results for patients. Through innovative research and multidisciplinary expertise and teamwork, it is hoped that patients with cancer may achieve improved health outcomes and prolonged survival from their H treatments. ■
This article was submitted by Shirin Abadi, BC Cancer. www.hospitalnews.com
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NAPRA Pharmacy Cleanrooms
Practical considerations for design, construction and maintenance ospitals across the country are in the process of determining how they will address the facility requirements contained in the latest model standards released by the National Association of Pharmacy Regulating Authorities (NAPRA). The new requirements apply to both Sterile Compounding and Hazardous Compounding facilities and introduce the requirement to meet cleanroom construction and operation standards for the facility. Specific design challenges for hospitals include: how to upgrade existing facilities while maintaining services, ensuring the existing building services could support the rooms, and optimizing the design for process flow and productivity while keeping staff and patients safe. Cleanrooms require sophisticated wall construction and HVAC which can be a challenge to implement in some areas. Available cooling, power, and floor-to-ceiling
space can be big factors in determining the location of these pharmacies. Similarly, hazardous compounding suites must be vented directly outdoors and incorporate proper exhaust clearances and dilution. In most cases a modular cleanroom solution offers considerable benefits including cleanroom grade wall/ceiling systems, faster assembly resulting is less down-time and impact to staff and patients. The assembly is often designed to fit within the available space. In addition to meeting NAPRA and CSA design requirements, the new facilities focus on providing a flexible and productive space for staff. Construction of pharmacy cleanrooms requires significant attention to detail. Cleanroom providers have systems which allow for completely flush surfaces for windows, doors, and other components of the room. The ISO standard 14644 requires all room corners to be coved, including at ceilings and floors. Doors, walls, and ser-
vices mounted in rooms must be airtight to ensure pressure control can be achieved. Modular cleanrooms have embedded raceways for electrical, services, and low-level returns which make sealing the environment easier to achieve. Critical to cleanroom construction is selection of wall materials that are suitable for the harsh chemical cleaning agents that are required. Surface treatments such as uPVC and stainless steel are preferred. During installation of the cleanroom there must be careful consideration to how the equipment, services, casework, and wall system interface. Coving on wall interfaces restrict placement of casework and equipment. Similarly, any ledges or flat surfaces must be minimized, often requiring shrouds to ensure the room can be effectively cleaned. Allowance must be made to ensure equipment can be moved into the space once all walls and doors are in place. Every opening into the room, including electrical, IT,
plumbing, and services must be completely sealed to ensure pressure control is maintained. Operation considerations include a pressure monitoring and recording system to ensure spaces meet required performance. Systems integrated to the facilities Building Automation system gives building operators access to monitor the cleanroom continuously, and safely retain data. The HEPA filter units can include LED status indicators letting staff know if any maintenance is required. Use of glazing and half lights on the doors provide good visibility into the space and reduce any claustrophobic effect. Pharmacy compounding rooms constructed to meet the new NAPRA model standards offer a new level of safety for staff and patients. Introducing cleanroom standards to the operation of these facilities can be an opportunity to revisit compounding operations, improve overall process flow, and ultimately protect both staff and patients.
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Pharmacists also work in primary care clinics? harmacists who work in primary care clinics (or family health teams) are becoming more commonplace in Canada; they provide a number of services to improve the healthcare people receive. One of the most important things they do is involve people in decision making surrounding their medications. Due to the complexity of modern medicine, choosing the best treatment for chronic diseases is no easy task. Pharmacists working in primary care settings frequently have thorough discussions with patients and prescribers about the often numerous medication options for treating chronic diseases. Using their expertise in medications, they help patients clearly understand
the benefits, risks, and costs of medications to allow patients to decide which medication would best suit them. The less acute nature of primary care clinics provides enough time for all parties involved to review this information and agree on the best course of action. After a decision about treatment is made, the pharmacist, patient, and prescribers continue to work together at follow up visits. During these appointments the primary care pharmacist supports dose optimization, and monitors how well the medication is working. The appointments also provide opportunities to work closely with the patient to manage or resolve any adverse effects the patient is having due to medications. Periodically, pharmacists will check in to ensure the
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PHARMACISTS WORKING IN PRIMARY CARE SETTINGS ALSO HAVE A ROLE IN ENSURING THAT WHEN THE PATIENT IS ADMITTED TO A HEALTHCARE INSTITUTION (SUCH AS A HOSPITAL) THAT THE TRANSFER IN CARE IS DONE AS SAFELY AS POSSIBLE medications continue to meet the patientâ€™s and providerâ€™s goals, and consider safely discontinuing (deprescribing) medications if they are not. Pharmacists working in primary care settings also have a role in ensuring that when the patient is admitted to a healthcare institution (such as a hospital) that the transfer in care is done as safely as possible. Making sure appropriate information about the patientâ€™s medication flows from the primary care home to acute care facilities and back again after an acute care stay can reduce medication mis-
adventures and prevent readmissions to hospital. Pharmacists also educate patients on any medication changes that may have resulted from an admission, reinforcing any learning that occurred while the patient is still in the hospital. These are a few of the roles that pharmacists working in primary care perform on a daily basis to improve the health of the people they interact with. Ask if there is a pharmacist on your healthcare team that can work with you to educate you about, and H optimize your medications. â–
This article was submitted by Robert Pammett, Northern Health. 30 HOSPITAL NEWS JUNE 2018
“CPDN’s Drug Shortage Allocation Tool is invaluable. The ability to equitably manage supply when there are shortages helps keep our hospital running.” - Hospital pharmacist
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Pharmacists in the
can do so much more harmacists are quite often found in emergency departments (ED); working away to gather a best possible medication history from patients; and performing medication reconciliation for admission to hospital. A Best Possible Medication History is when a health care provider compares the list of medications provided by a patient or caregiver, to another reliable source of information â€“ such as the medication profile kept from
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your community pharmacy or a recent hospital visit. Having two sources of information helps to ensure the accuracy. Then, when there is a decision to admit a patient, OR to return home but with a modification of medication, the pharmacist will compare the medication lists from before coming to hospital and after coming to hospital to ensure that there are no differences in the lists and that the patient is receiving the medication they are supposed to and none that they arenâ€™t supposed to. www.hospitalnews.com
CANADIAN SOCIETY OF HOSPITAL PHARMACISTS
STUDIES HAVE SHOWN THAT A MAJORITY OF VISITS TO AN EMERGENCY DEPARTMENT CAN BE CLASSIFIED AS MEDICATION RELATED For this reason, it is always important to bring an updated list to the ED from your pharmacy, or bring with you all the medications you take on a regular basis.
BUT DID YOU KNOW THE PHARMACIST IN THE ED CAN DO SO MUCH MORE?
Pharmacists are the health care provider best suited to provide information about medications. Studies have shown that a majority of visits to an ED can be classified as medication related. Having a pharmacist to review the history of why a patient may be
presenting to the department can help inform either the cause for this visit or prevent any future drug related issues occurring in the future as a result of treatments received or prescribed in the ED. In most provinces in Canada, pharmacists are able to prescribe for minor ailments and prescribe independently in collaborative practice with physicians and when given a diagnosis. Because of this, a pharmacist working in the ED is able to assess the need for medication and prescribe under certain conditions. The pharmacist can review lab results and follow up with patients if
they need treatment with antibiotics. This is one way that pharmacists can also help to ease the burden in busy emergency departments. Another area where the unique skill set of a pharmacist can be used is during traumas or resuscitations. A pharmacist has unique knowledge of medication use during these high stakes situations, and can anticipate the needs of the patient with respect to medications – have the doses prepared and ready to administer when asked for. This helps to save valuable
minutes; and ensures that nurses are at the bedside caring for their critically ill patient. One final area a pharmacist can provide useful assistance is our knowledge of drug toxicities and overdoses. Intentional and accidental overdoses are managed in the emergency department; and a pharmacist is able to gather the history of ingestion, confirm the substance and quantity, as well as recommend on the antidote to be given, dose, and parameters for monitoring H recovery. n
IN MOST PROVINCES IN CANADA, PHARMACISTS ARE ABLE TO PRESCRIBE FOR MINOR AILMENTS AND PRESCRIBE INDEPENDENTLY IN COLLABORATIVE PRACTICE WITH PHYSICIANS AND WHEN GIVEN A DIAGNOSIS
This article was submitted by Melanie MacInnis, IWK Health Centre (located in Halifax).
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Medication Safety Exchange ealthcare organizations providing patient care in Canada analyze medication incidents that occur in their organizations. The valuable knowledge gained from these local analyses can benefit other healthcare providers and organizations, and importantly – prevent patient harm from similar incidents. The Med Safety Exchange is a webinar series hosted by the Institute for Safe Medication Practices Canada (ISMP Canada) that offers a dynamic and supportive mechanism for shared knowledge while supporting the dissemination of incident learning. It fosters a learning culture and the development of strategies and safeguards for preventing patient harm. The first six webinars held from September 2017 to February 2018, reflected national interest and participation, with participation from all provinces and most territories. Webinar presenters represented both grassroots facilities as well as national organizations, such as the Canadian Patient Safety Institute (CPSI), Health Canada, ISMP Canada (including the Community Pharmacy Reporting Program – CPhIR), the Canadian Institute for Health Information (CIHI), and the Canadian Society of Hospital Pharmacists (CSHP).
Participants’ responses to a post-webinar survey demonstrated perceived utility of the medication safety-related learnings, willingness to implement presented recommendations to optimize medication safety, and the value of medication incident reporting (Figure 1).
THE MED SAFETY EXCHANGE IS A WEBINAR SERIES HOSTED BY THE INSTITUTE FOR SAFE MEDICATION PRACTICES CANADA (ISMP CANADA) The success of the pilot demonstrated that the Med Safety Exchange is a valuable, practical, and beneficial program to promote reporting, sharing, and learning for all healthcare practitioners across Canada. Visit the website (https://www.ismp-canada. org/MedSafetyExchange/) to register for the next webinar, and contact email@example.com to share learning from your medication incident analyses and your medication H safety initiatives! ■
Figure 1: Responses to the post-webinar survey questions related to medication safety culture. This article was submitted by Ambika Sharma, Pharmacist and Michael Hamilton, Physician, ISMP Canada. 34 HOSPITAL NEWS JUNE 2018
Telepharmacy services in Canada By Sammu Dhaliwall ith its large land mass and population density in relatively few pockets, Canada’s hospital pharmacy departments across the country face immense challenges providing pharmacist services. Many remote and rural communities are unable to recruit the services of a pharmacist for daytime work, and don’t have the economies of scale to keep a full time pharmacist busy. As technologies have advanced to improve the safety of medication distribution systems, even urban hospitals in populated areas have yet to embrace the true safety nets that pharmacists bring when medication orders are verified around-the-clock. The vast majority of hospital pharmacies still shut down overnight, despite the fact that healthcare is 24/7 and many of our sickest patients are ordered medications overnight. For such reasons, telepharmacy has been a growing service offer for health institutions over the past 15 years. The Canadian Society of Hospital Pharmacists defines telepharmacy as “The use of telecommunications technology to facilitate or enable the delivery of high-quality pharmacy services in situations where the patient or healthcare team does not have direct (in-person) contact with pharmacy staff.”1 Telepharmacy can be used to in many ways, for example, clinically review new orders 24/7, remotely check sterile IV preparations, or provide counseling to patients at discharge from the hospital. The first recognized telepharmacy services in Canada were within some of the health regions of British Columbia and New Brunswick in 2003, in which larger regional hospitals helped review orders for certain small hospitals that didn’t have regular onsite pharmacists to help support the patients. In 2004, a private telepharmacy company started providing remote clinical order review to a hospital in Moose Factory, Ontario, as the hospital
was not able to recruit a pharmacist. This telepharmacy company today services over 45 hospitals, providing remote clinical order review around-the-clock and additionally helps pharmacy departments meet medication management standards by experimenting with videoconference technologies (including Ontario Telemedicine Network’s secure links to healthcare institutions). While there are many other current examples of telepharmacy services provided across the country, large gaps remain, leaving many deficiencies in pharmacy services. Technologies utilized to provide Telepharmacy in Canada include:
MEDICATION ORDER MANAGEMENT SOLUTIONS • Allowing nurses to scan physician medication orders securely to the remote pharmacist in hospitals which are still mostly paper-based • Enable one pharmacist to manage multiple hospitals simultaneously with clinical support and specific medication reviews overnight to improve efficiencies and safety
VIDEOCONFERENCE SOLUTIONS • Allowing pharmacists to communicate with patients for education and discharge counselling • Enabling pharmacists to communicate with physicians, nurses and other healthcare providers.
REMOTE CAMERA VERIFICATION SOLUTIONS (which bring telepharmacy support to one of the highest risk areas of hospital pharmacy – compounding of sterile products, chemotherapy, and non-sterile medications): • Allowing for remote check of compounded products by pharmacist or pharmacy technician and future traceability of products if errors are suspected or recalls occur. www.hospitalnews.com
CANADIAN SOCIETY OF HOSPITAL PHARMACISTS
TELEPHARMACY AS “THE USE OF TELECOMMUNICATIONS TECHNOLOGY TO FACILITATE OR ENABLE THE DELIVERY OF HIGHQUALITY PHARMACY SERVICES IN SITUATIONS WHERE THE PATIENT OR HEALTHCARE TEAM DOES NOT HAVE DIRECT (IN-PERSON) CONTACT WITH PHARMACY STAFF • Successfully implemented in Newfoundland & Labrador enabling chemotherapy products to be prepared in remote hospitals, allowing patients to receive life-saving therapy closer to home Although telepharmacy has been used by Canadian hospitals for over
15 years, there is a need for expansion of its use in the future, to allow for advancement in how pharmacy services are delivered to and received by patients and to provide all patients, regardless of geographical location in Canada, the same H standard of care. ■
This article was submitted by Sammu Dhaliwall, Telepharmacy Services Solutions.
Pharmacy Services 24/7 Improves Patient Safety All 3 cases occurred in the late evening/overnight period, when the hospital pharmacy department was closed, and the telepharmacy service was in place, ensuring the safety of all prescribed medications. Case 1: An order for dalteparin (an anticoagulant) was prescribed with a dose of 2,500 units (prevention of deep vein thrombosis (DVT) dosing). After review and investigation, the telepharmacist determined that the patient actually had (DVT), and required a full treatment dose instead. The telepharmacist determined that the physician’s intended dose was 25,000 units (a zero was left off by mistake) As the patient was obese, the telepharmacist determined 12,500 units twice daily was a safer and more effective option and got the order changed to this. Prompt pharmacist review right after prescribing, resulted in the patient receiving the correct dose immediately, for a serious, potentially life-threatening condition. Case 2: Patient X was admitted to hospital with an order for long-acting Isosorbide Monohydrate (ISMN) once daily. As ISMN was not on hospital formulary and not stocked by the hospital, the nurse decided to substitute with an equivalent dose of Isosorbide Dinitrate (ISDN) once daily. Upon reviewing the order, the telepharmacist advised the nurse that the two are not equivalent and determined that the patient had her own supply of ISMN which the pharmacist instructed the nurse to use instead, thus preventing the wrong medication from being administered. Case 3: An order was received for warfarin 4.5 mg to be given now. The telepharmacist noted that the patient’s INR (a measure of how long it takes the blood to clot) was too high and noted that the admitting diagnosis was a nose bleed. The telepharmacist immediately intervened to get the warfarin order held and ensured that the INR would be checked and warfarin reassessed the next day. The immediate action of the telepharmacist in this case, ensured the best chance of a positive outcome, by preventing a potentially serious bleed. Contact Northwest Telepharmacy Solutions to prevent medication errors from occurring while the inpatient pharmacy is closed after-hours and on weekends. No patient deserves a medication error.
JUNE 2018 HOSPITAL NEWS 35
residency training in canada
any pharmacists working in hospitals have completed a pharmacy residency program. What are pharmacy residencies? They are structured, post-graduate education programs designed to enhance pharmacist skills, knowledge and abilities. These programs build upon the foundational skills learned in pharmacy programs. Through structured rotations in pharmacy practice, education, research, and administration, residency programs aim to prepare pharmacists for challenging and innovative pharmacy practice. Graduate of
pharmacy residency programs are an important source of highly qualified pharmacists trained in institutional practice. In Canada, pharmacy residency programs deliver their educational content in alignment with published residency standards that are established by the Canadian Pharmacy Residency Board (an affiliated board of the Canadian Society of Hospital Pharmacists). The 2018 Accreditation Standards for Pharmacy (Year 1) Residencies are designed to develop pharmacists who are proficient in providing direct patient care in a variety of clinical settings.
BD is one of the largest global medical technology companies in the world and is advancing the world of health by improving medical discovery, diagnostics and the delivery of care. The company develops innovative technology, services and solutions that help advance both clinical therapy for patients and clinical process for health care providers. BD has 65,000 employees and a presence in virtually every country around the world to address some of the most challenging global health issues. BD helps customers enhance outcomes, lower costs, increase efficiencies, improve safety and expand access to health care.
bd.com 36 HOSPITAL NEWS JUNE 2018
PHARMACY RESIDENCIES ARE STRUCTURED, POST-GRADUATE EDUCATION PROGRAMS DESIGNED TO ENHANCE PHARMACIST SKILLS, KNOWLEDGE AND ABILITIES As well, graduates gain competency in pharmacy operations, project management, education, practice management, and leadership. The 2016 Accreditation Standards for Advanced (Year 2) Pharmacy Residencies build upon the competencies developed in a Year 1 Pharmacy Residency, and further refine these skills in a defined area of practice (specific therapeutic area, patient population or type of practice). Residents of these programs are expected to demonstrate expertise in direct patient care. These programs also focus on teaching and research. There are 34 accredited Pharmacy (Year 1) Residency Programs and three accreditation-pending Pharmacy (Year 1) Residency Programs. There is currently one accreditation-pending Advanced (Year 2) Pharmacy Residency Program, with several other programs currently under development. These programs operate in 9 of the 10 Canadian provinces and range
in size from a single resident to over 45 residents. While all of these programs are designed to comply with the corresponding residency standards, differences between programs exist in requirements and experiences. Some programs are offered in specialty areas, including pediatrics, mental health, cancer care and primary care, while others are offered in general practice settings. In spite of these differences in practice experiences and requirements, all residency graduates will meet the required competencies upon graduation and will be granted use of the ACPR or ACPR2 designation for the Year 1 or Year 2 program, respectively. Graduates from these programs go on to work in a variety of roles such as clinical pharmacists, clinical pharmacy specialists, pharmacy leaders, educators and researchers. More information on Residency Programs in Canada can be found on the Canadian Pharmacy Residency Board website H (https://cshp.ca/cprb). â–
This article was submitted by Jennifer Bolt, Canadian Pharmacy Residency Board, Chair. www.hospitalnews.com
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TO ADDRESS YOUR CONCERNS REGARDING DRUG WASTAGE. At BD, we understand the importance of readiness, especially with the new beyond-use dating requirements as part of the NAPRA Model Standards just around the corner. A key imperative for Canadian pharmacies will be managing the costs associated with these new standards. The BD PhaSeal ™ closed-system drug transfer device (CSTD) is a system that can both alleviate safety concerns and potentially drive savings to your bottom line as part of a drug vial optimization (DVO) program.1 With decades of conversion management expertise here in Canada, you can rely on BD to guide you through a custom conversion program suited precisely to your unique needs. Discover the difference of the right partner. Discover the new BD.
Speak today with your BD representative about BD HDS solutions, including the BD PhaSeal™ and Texium™ systems, or email PhaSeal.Canada@bd.com 1 Carey ET, Forrey RA, Haughs RD, et al. Second look at utilization of a closed-system transfer device (PhaSeal). Am J Pharm Benefts. 2011;3(6):311–318. © 2018 BD. BD, the BD Logo and all other trademarks are property of Becton, Dickinson and Company. MC9062
JUNE 2018 HOSPITAL NEWS 37
CANADIAN SOCIETY OF HOSPITAL PHARMACISTS
Opioids for pain after surgery: Your questions answered – resource for patients urgical patients are four times more likely to receive opioids at discharge from hospital than their non-surgical counterparts. A recent study of post-surgical patients by Brat et al (2018), showed each additional week of opioid prescription is associated with a significant increase in opioid misuse among opioid-naïve patients. A patient resource, “Opioids for pain after surgery: Your questions answered” was developed collaboratively with, and endorsed by, Patients for Patient Safety Canada, the Canadian Patient Safety Institute (CPSI), the Canadian Society of Hospital Pharmacists (CSHP), the Canadian Deprescribing Network, Choos-
ing Wisely Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH), the Canadian Nurses Association (CNA), the Canadian Medical Association (CMA), the Canadian Association of General Surgeons, and the Institute for Safe Medication Practices Canada (ISMP Canada). This resource was developed in accordance with recent guidelines and preferred practices. The handout, which builds on the movement ‘5 Questions to Ask about Your Medications’, was launched by Choosing Wisely Canada through the Opioid Wisely Campaign. The aim is to equip patients with important messages in plain language about opioid use after surgery. Some
Pharmacy Capital Contract to Meet New NAPRA Standards HealthPRO is now accepting commitments from members for its Biosafety Cabinets and Hoods Contract. Ranging from Biosafety Cabinets, Laminar Flow Hoods and Compounding Isolators, including Class I, II and III protection levels for use in a variety of controlled environments, pharmacies and cleanrooms. For more information, please contact: Rafael Perez Director, Capital Equipment firstname.lastname@example.org
38 HOSPITAL NEWS JUNE 2018
THIS RESOURCE WAS DEVELOPED IN ACCORDANCE WITH RECENT GUIDELINES AND PREFERRED PRACTICES key messages include: use the lowest possible dose for the shortest possible time; opioids are usually required for less than one week after surgery; and ask about the use of other methods to reduce pain including non-opioid pain medications. The resource also advises patients to securely store medications and to return any unused medications to a community pharmacy. Improper storage or disposal of opioids has resulted in accidental poisonings, medication errors, and inappropriate use. The Health Product
Stewardship Association (www.healthsteward.ca) can be contacted for more information about locations that accept unused medication returns. Opioids for pain after surgery: Your Questions Answered is available: In English: https://www.ismp-canada.org/download/OpioidStewardship/ OpioidsAfterSurgery-EN.pdf In French: https://www.ismp-canada.org/download/OpioidStewardship/ OpioidsAfterSurgery-FR.pdf For more information about use of opiH oids, visit www.opioidstewardship.ca ■
This article was submitted by Alice Watt and Sylvia Hyland, Pharmacists, Institute for Safe Medication Practices Canada (ISMP Canada). www.hospitalnews.com
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It’s just culture, so what? onder for a moment any of the times that you or your colleagues were involved in a medical or medication incident – an incorrectly processed prescription, a miscalculated dose, or ordering a treatment intervention for the wrong patient perhaps? In the wake of such an incident, how did you or your colleagues react? Perhaps you experienced the tensing up upon realizing the error, followed by the desperation of looking for a solution. What are the underlying causes of your reaction? Is it fair that healthcare professionals should be exclusively blamed for or be held accountable for the failings of a healthcare system that they do not control? What are the problems with such a culture? Are there alternatives?
MINDFUL ORGANIZATIONS CONTINUALLY LEARN, ADJUST, AND REDESIGN SYSTEMS FOR SAFETY AND MANAGE BEHAVIOURAL CHOICES MATURELY BLAME CULTURE It is characterized by blame being attributed to outcomes rather than the actions leading to or the systematic factors that contributed to the outcomes. Disciplinary action is usually carried out against the healthcare professional(s) closest to the incident and the punishment is dispensed in order to deter future undesirable behaviour. Reprimands range from public condemnation and shame, documentation of disciplinary action in employee
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personnel files, and in extreme cases, termination. The typical response to a culture of blame is characterized by an unwillingness to take risks or accept responsibility for mistakes for fear of criticism or punishment. This causes people to blame each other in order to avoid the punishment. Healthcare practitioners will likely remain silent in response to performance problems, near misses, or professional errors. Such mistrustful silence will make incident analysis harder and more difficult to identify existing vulnerabilities in organizational processes that may inevitably result in recurring errors, regardless of the professional performing the task.
JUST CULTURE: AN ANTIDOTE In this type of culture, the goal is not blame but rather process improvement, ultimately to advance patient safety. Process improvement is a disciplinary approach in which an organization learns and improves by openly identifying and examining its own weaknesses. Members can openly question existing practices, express concerns, and admit mistakes without suffering ridicule or punishment. The complexity of the situation, determining factors that “allowed” or even “encouraged” the error, are considered. The individuals involved receive constructive feedback and fair-minded treatment. This kind of culture fosters mindfulness through-
out an organization. Mindful organizations continually learn, adjust, and redesign systems for safety and manage behavioural choices maturely. However, the main issue with this type of culture is that, if poorly implemented, it can result in worse outcomes than a blame culture. Therefore, a just culture requires careful consideration and well thought-out implementation. This is not an easy task, because the impact of quality improvement techniques and isolated training programs on cultural change has been shown to be limited.
CHANGING CULTURE: WHAT CAN WE DO ABOUT IT? Organizational culture cannot evolve sequentially, but requires a holistic approach. Without a fundamental change to the core values, norms, and expectations of the organization, change remains superficial and shortlived. Failed attempts to change may lead to cynicism, frustration, loss of trust, and deterioration in morale among members. It is only with the support of leadership and a human resources (HR) department that has the necessary institutional authority to implement consistent HR and professional practices that help shift general healthcare culture towards shared learning from incident analysis and just culture. In a practice environment with a just culture, all members of the healthcare team understand their ethical responsibility to call out defects, including their own, in the system of care without fear of retribution. In such a culture, healthcare professionals can feel at ease, safe in the knowledge that their mistakes will not necessarily lead to punishment but will always lead to systematic corrections and institutionH al improvements. ■
To learn more, visit www.omnicell.com Aleksa Stankic is a PharmD Student at the Leslie Dan Faculty of Pharmacy, University of Toronto; Certina Ho is a Project Lead at the Institute for Safe Medication Practices Canada (ISMP Canada). 40 HOSPITAL NEWS JUNE 2018
CANADIAN SOCIETY OF HOSPITAL PHARMACISTS
What is in hospital pharmacy practice? atient-centred care. Best practice. Communication and collaboration. It’s no coincidence that these are the three themes of CSHP’s program, Excellence in Hospital Pharmacy. CSHP’s Excellence in Hospital Pharmacy program is a multi-year initiative that aligns with CSHP’s Strategic Plan (to 2020). Patients are our focus. Excellence will assist pharmacy teams to strive to provide exceptional care to patients and help improve patient health outcomes. It is specifically designed to assist members in focusing their efforts towards fostering excellence
PATIENT-CENTRED CARE. BEST PRACTICE. COMMUNICATION AND COLLABORATION.
and innovation in patient care. The overarching goal for the program is “Improving Patient Health Outcomes”. Excellence draws on many of the expectations laid out in CSHP’s Phar-
macy Practice in Hospitals and Other Collaborative Healthcare Settings: Position Statements. The collection of statements in this publication “describes a desired and achievable level of performance that is applicable to
the practice of pharmacy in a healthcare organization, regardless of geographical location, experience, or area of practice.” As such, it describes the high quality of patient-centred care that patients should receive from its hospital pharmacy staff. The statements also recognise that pharmacy personnel do not work alone, but rather are partners in care, working closely with the patient and with other healthcare workers. And, that this care cannot be provided without being good stewards of the resources given to manage how medications are used throughout the healthcare H organization. ■
JUNE 2018 HOSPITAL NEWS 41
Making a difference around these key themes: Patient Engagement/Patient-Centredness Best Practice, including Patient Safety Effective Communication and Collaborative Practice Listens Values
iples, 3 th princ em 6 s,
Improving patient health outcomes.
Collaborates The pharmacist develops and assesses the pharmacy care plan in collaboration with other members of the healthcare team. • Proportion of patients who receive comprehensive direct patient care from a pharmacist working in collaboration with the health care team. (cpKPI1) • Proportion of patients for whom a pharmacist participates in interprofessional patient care rounds to improve medication management. (cpKPI1) • Proportion of pharmacists whose practice includes advanced practice roles. 1
Cares The pharmacist provides proactive patient-centred care to develop a pharmacy care plan that reflects the patient’s goals. • Proportion of patients for whom a pharmacist has developed and initiated a pharmacy care plan. (cpKPI1) • Proportion of patients who receive education from a pharmacist about their disease(s) and medication(s) during their hospital stay. (cpKPI1) • Proportion of patients who receive medication education from a pharmacist at discharge. (cpKPI1) • Extent of patient-reported involvement in care decisions.
Implements The pharmacy department implements risk-reduction strategies to improve the safety of the medication-use system. • Implementation of medication system risk-reduction strategies. • Evaluation of the impact of medication system risk-reduction strategies.
Fernandes O, Toombs K, Pereira T, Lyder C, Bjelajac Mejia A, Shalansky S, et al. Canadian consensus on clinical pharmacy key performance indicators: knowledge mobilization guide. Ottawa, ON: Canadian Society of Hospital Pharmacists; 2015.
cshp.ca/excellence 42 HOSPITAL NEWS JUNE 2018
ason 1 re es,
Communicates The pharmacist communicates the plan of care to the professionals who will assume responsibility for care of the patient at care transitions. • Proportion of patients whose plan at transition of care is communicated to the appropriate health care provider. • Proportion of patients who receive documented medication reconciliation at discharge (as well as resolution of identified discrepancies), performed by a pharmacist. (cpKPI1)
15 mea sur e
The pharmacy team views patients as valuable, effective partners in shared decision-making. • Presence of patient experience advisors participating on at least one pharmacy committee or working group. • Implementation of tools for staff and leadership that include expectations regarding patient-centred care.
The pharmacy team listens to, understands, and respects the patient’s story about experiences and expectations that will affect the use of medications. • Extent of patient-reported communication with the pharmacy team. • Extent of patient-reported satisfaction with their interactions with the pharmacy team.
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for the elderly in long-term care residences
By Dale Mayerson and Karen Thompson ater is essential for life and humans cannot live more than a few days without it. Water comprises about 50 to 70 per cent of human body weight and plays a role in almost every biochemical reaction. Dehydration is defined as a harmful reduction in the amount of water in the body. Dehydration is common with seniors living in the community and can be an issue for those living in long-term care.
44 HOSPITAL NEWS JUNE 2018
WHY ARE SENIORS AT RISK? There are several factors that can increase the risk of dehydration for residents including: diminishing thirst sensation, decreasing ability to eat and drink independently, not asking for drinks, and the dehydrating effects of many medications. Residents may refuse to drink due to embarrassment related to urinary incontinence, while those with cognitive impairment may refuse drinks, even with cueing and
encouragement. Residents taking diuretics may also tend to stay in their rooms, since urine output can be more frequent than normal. Residents who have dysphagia are also at an increased risk of dehydration. Thickened fluids are not as well-liked as thin fluids such as water or juice, and so not as much is taken. Dehydration risk is most concerning when there is vomiting, diarrhea and fever, since water loss in these circumstances can be very high and fluids need to be immediately replaced.
RISKS ASSOCIATED WITH DEHYDRATION Dehydration for seniors can lead to an increased risk for falls. Since osteoporosis is a concern for many seniors, both men and women, the results of a fall can mean a fracture of a hip, or spinal column or wrist. This can change a seniorâ€™s entire life, leaving them less mobile, possibly in a wheelchair, with a greater need for assistance with activities of daily living, potentially requiring a change in living conditions. www.hospitalnews.com
LONG-TERM CARE NEWS
THERE ARE SEVERAL FACTORS THAT CAN INCREASE THE RISK OF DEHYDRATION FOR RESIDENTS INCLUDING: DIMINISHING THIRST SENSATION, DECREASING ABILITY TO EAT AND DRINK INDEPENDENTLY, NOT ASKING FOR DRINKS, AND THE DEHYDRATING EFFECTS OF MANY MEDICATIONS Constipation is another concern for seniors, which can be related to a decrease in physical activity and less than adequate fibre in the diet. Additionally other health concerns contribute to constipation such as stroke, Parkinson’s Disease, hypothyroidism, diabetes, etc., as well as it being a side effect of many medications. Poor fluid intake can also cause constipation or at least exacerbate the situation, since water intake helps to move stool through the large intestine. Adequate fluid intake is important to alleviate this problem and is an essential part of prevention. Residents with constipation may be uncomfortable which can also lead to involvement in fewer activities.
Skin health is maintained or improved with good nutrition and hydration. Dry, thin, frail skin is more likely to break down and form open areas which can leak fluids, leading to greater risk of dehydration.
DEHYDRATION PREVENTION IN LTC Residents in long term care should be offered fluids frequently. Meals should include water, juice, milk as well as coffee or tea. Drinks are offered at snack times between meals, and smaller amounts are provided with medications and may also be offered at various activities and events
in the home. Estimated fluid needs are calculated based on residents’ weights, but appropriate intake for many is approximately a minimum of 1500 ml or six cups of fluids per day. This does not include high fluid foods such as soup, yogurt, fruits, vegetables and other foods. Residents who are dehydrated are at greater risk of hospitalization and may require intravenous therapy. To avoid this situation, processes for adequate hydration should be implemented. These may include: • Posting a list that identifies residents at risk of dehydration and updating this list frequently • Providing drinks every hour from a hydration cart for those at high risk • Making fluids readily available during hot weather so family, staff and volunteers can offer it to residents • Offering fluids frequently during meal and snack times (not just once), to maximize drinking opportunities • Offering sips between bites of food for residents being fed • Offering water with medications
• Offering fluids after resident has used the toilet • Providing encouragement and assistance for meals and snacks as this has shown to improve intake • Starting a “sip and go” program so that anyone entering a resident’s room can offer a sip of water • Educating and training staff and volunteers to be aware of the need for fluid intake • Informing RN/RPN when there are warning signs for dehydration i.e. dark urine, increased confusion etc. • Increasing the monitoring of those residents at risk i.e. those with a history of dehydration, those on thickened fluids • Providing hypodermoclysis, or water provided subcutaneously (under the skin) • Maintaining a clear and simple system for documenting fluid intake that flags those residents that may be at risk Hydration is a key part of good health and everyone working and visiting in long-term care should be aware of their role in improving hydration status for residents. LC
Dale Mayerson B Sc RD CDE, and Karen Thompson, B A Sc RD are Registered Dietitians with extensive experience in Long-term care. They are co-authors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide.”
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Runnymede Healthcare Centre
establishes itself as community healthcare hub By Carla Wintersgill unnymede Healthcare Centre is embarking on a groundbreaking initiative to build a 200-bed longterm care (LTC) home adjacent to the existing hospital. On May 1, 2018, Ontario’s Ministry of Health and Long-Term Care announced it would provide funding for Runnymede’s LTC home as Runnymede transforms into a community health hub.
BY PROVIDING ACTIVE AND SLOW STREAM REHABILITATION, MEDICALLY COMPLEX CARE AND LONG-TERM CARE SERVICES, RUNNYMEDE HAS SOLIDIFIED ITS POSITION AS A COMMUNITY HEALTH HUB “Our government is committed to supporting Ontario residents who rely on long-term care homes for their ongoing health and personal care needs. By adding 200 new long-term
Runnymede Healthcare Centre President & Chief Executive Officer, Connie Dejak (second from right) is joined by MPP for Etobicoke Centre, Yvan Baker, The Honourable Laura Albanese, Minister of Citizenship and Immigration and MPP for York South – Weston, and Maltese Canadian Federation President, Joe Sherri at Queen’s Park. care beds to the redevelopment of the Runnymede Hospital, we are helping more seniors access the care they need in their community, close to family and friends,” says Dr. Helena Jaczek, Minister of Health and Long-Term Care.
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Runnymede’s new LTC home will allow patients to receive desperately needed care closer to home, including the local Maltese population. Runnymede is situated in the heart of Little Malta and this cultural group does not have a LTC facility or dedicated program anywhere in Ontario. “We are absolutely thrilled by the provincial government’s announcement that we will receive funding to build a long-term care home on our site. Runnymede Healthcare Centre has a history of providing excellent, patient-focused care. The addition of a long-term care facility to our campus will allow Runnymede to provide comprehensive services for generations to come,” Runnymede President and CEO Connie Dejak says.
By providing active and slow stream rehabilitation, medically complex care and long-term care services, Runnymede has solidified its position as a Community Health Hub. “Seniors are a growing population in my riding of York South-Weston and beyond, and I believe that they deserve the very best care and support we can provide. That is why as part of our government’s plan to increases access to high-quality long-term care, including the commitment to adding 200 long-care beds to the redevelopment of Runnymede Hospital, we are ensuring that communities across Toronto West are receiving high quality care,” says Laura Albanese, MPP York H South-Weston. ■
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Carla Wintersgill is a Communications Specialist at Runnymede Healthcare Centre. www.hospitalnews.com
LONG-TERM CARE NEWS
One in four Canadian seniors on 10 or more prescriptions drugs By Julie Bortolotti t isn’t surprising to hear that as people get older, they require prescription medication to help address medical conditions associated with aging. But, a new report found that many of Canada’s seniors are being prescribed a lot of drugs. About one in four seniors are prescribed 10 or more drugs, according to a report from the Canadian Institute for Health Information (CIHI). CIHI’s report showed that the number of drugs prescribed to seniors hasn’t changed significantly since 2011. However, several initiatives appear to have been successful in reducing the use of some prescription drugs, including antipsychotics (used to treat schizophrenia and bipolar disorder) and benzodiazepines (used for anxiety and insomnia). Drugs used to treat high cholesterol – used by nearly half of all seniors – were the most commonly prescribed drug class. Other common drug classes prescribed among seniors included drugs for acid reflux disease, peptic ulcer disease and high blood pressure.
WHO IS PRESCRIBED THE MOST DRUGS? The number of drugs prescribed increases with age. In 2016, about 21 per cent of seniors age 65 to 74 had claims for 10 or more drugs, compared to about 38 per cent of seniors age 85 and older. Seniors who are women, live in a rural area or a low-income area are also more likely to take more drugs. There are several factors that may explain www.hospitalnews.com
these findings. Women tend to have more chronic conditions, they seek out more preventive care than men do, and they live longer than men, on average. Seniors in low-income neighbourhoods could take more drugs due to differences in health status by income. For example, Canadians with the lowest income were twice as likely to report living with cardiovascular disease than those with the highest income. Experts suggest the difference is rural and urban drug use could be because people who live in rural areas may have less access to resources, including care providers and alternative treatment options.
MORE DRUGS = MORE HOSPITAL VISITS Seniors who were prescribed 10+ drugs were more likely to be hospitalized for an adverse drug reaction – over five times more likely than seniors who were prescribed fewer drugs. An adverse drug reaction could include falls, fractures and mental impairment. Cancer drugs, opioids and blood thinners were the most common drug classes that led to hospitalizations for adverse drug reactions. Because seniors need to take multiple drugs to manage their conditions, regular medication reviews with a pharmacists and/or physician can help reduce the risk of an adverse drug reaction. Potentially inappropriate drugs can also increase the risk of adverse effects and there are often safer alternatives. Commonly used drug classes such as proton pump inhibitors (used for acid reflux disease and peptic ulcer disease)
and benzodiazepines are among the drugs considered to be potentially inappropriate under certain circumstances. “Physicians want people to feel their best as they age and that often involves many prescription drugs,” says Jeff Proulx, program lead of Phar-
maceuticals at the Canadian Institute for Health Information. “We hope our report creates awareness around seniors’ drug use. We want seniors and their families feel encouraged to talk to their pharmacist or physician about H their medications.” ■
Julie Bortolotti is a Communications Specialist at The Canadian Institute for Health Information (CIHI).
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LONG-TERM CARE NEWS
Cycling without age
Enhancing the lives of seniors – the Ottawa experience By Michaela Berniquez the average ride was 60 minutes long and each participating resident had an average of three rides in the warm summer months. The first season was an overall success, with a 99 per cent satisfaction rate. Participants commented on their enjoyment of the rides and the beauty of nature, bringing laughter and smiles as they waved at the neighbours passing them on the bike path and in the community. Pilots shared in that enjoyment, loving the exercise, nature, and discussions with new friends. The launch was similarly successful at Élisabeth Bruyère Residence in 2017, proving that this program can run in both homey suburban and busy urban settings.
hat images come to mind when thinking about community? Strolling around, admiring the neighbors’ gardens, seeing children play, walking to work or to shops… These thoughts about a community are all related to enjoying the outdoor environment. What happens when someone is held back from enjoying this outdoor environment? The risk of isolation and loneliness grows. As people age, their bodies often become frailer and their range of movement can become more restricted, making it much harder to get outdoors. This would cause isolation and loneliness in anyone, let alone the often frail people living in long-term care. Recognizing the benefits, Therapeutic Support Services staff at Bruyère Continuing Care decided to look for ways to get residents outdoors. When the idea of Cycling Without Age was proposed, they could not turn the opportunity down.
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WHAT IS CYCLING WITHOUT AGE? Cycling Without Age (CWA) is an innovative program that helps seniors stay active and stay connected with their communities. Originating from Demark, CWA makes it possible for seniors or those with mobility challenges to get back on bicycles, allowing them to enjoy their scenic communities. This initiative started in 2012, and has expanded to 28 different countries. CWA uses a special 3-wheeled rickshaw bike. These “trishaws” have a two-seater passenger carriage in the front. They are propelled by volunteer “pilots” who sit on a bike in the back. The bike pilot can easily chat with the passengers, often connecting people from different generations through conversation, storytelling, and reminiscing.
A relaxing Cycling Without Age ride through the nature trails surrounding Saint-Louis Residence.
CYCLING WITHOUT AGE AT BRUYÈRE Bruyère Continuing Care (Bruyère) opened Ontario’s first CWA chapter in 2016, in collaboration with community partner Gary Bradshaw. The program evaluation was supported by the Bruyère Centre for Learning, Research and Innovation in Long-Term Care (CLRI). Bruyère runs two long-term care homes, Saint-Louis Residence and Élisabeth Bruyère Residence and also operates the Bruyère Village for independent seniors’ living, all located in Ottawa.
Bruyère’s Therapeutic Support Services Department runs the CWA program at all of these Bruyère sites, and has had tremendous success. In the first summer season of the program, the CWA program served 46 residents of Saint-Louis Residence, or one in four who live in the Residence, as well as 48 Bruyère Village tenants, family members and friends who accompanied residents on their outings. With such a high demand, over 121 hours were pedaled in that first summer alone. Alternating between more than 34 trained volunteer bike pilots,
Most recently, the Bruyère CLRI hosted a webinar covering the CWA program. Presented by Kim Durst-Mackenzie (Therapeutic Recreation and Volunteer Coordinator, Bruyère) and Gary Bradshaw, (Community Partner), the webinar focuses on the concept of CWA and why it is an essential program, as well as offers a more detailed explanation of the ins-and-outs of running CWA in longterm care homes with a large group of dedicated volunteers. To watch this webinar, please visit http://clri-ltc.ca/2018/03/cycling_ without_age_webinar_recording/. A program brochure is available on the CLRI website at clri-ltc.ca. This article draws on the findings of the evaluation of the first season of the Bruyère Cycling Without Age program, that was partially supported by the Government of Ontario through the Bruyère Centre for Learning, Research and Innovation in Long-term Care. Opinions expressed in this report do not necessarily reflect those of the Government of H Ontario. ■
Michaela Berniquez is a Communications Assistant at Bruyère Research Institute and Bruyère Centre for Learning, Research and Innovation in Long-Term Care. 48 HOSPITAL NEWS JUNE 2018
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in residential senior care
By Susan C. Jenkins eniors use more prescription medications than any other group in Canada, partly because older people are more likely to have more than one health condition. In fact, 25 per cent of Canadians over the age of 65 have at least three chronic health problems. When prescribed and supervised properly, taking multiple medications can increase both the duration and quality of life for seniors. However, it also increases the risk of drug interactions, frailty, disability, cognitive difficulties, and hospitalizations. This has led to a move toward deprescribing, in which people are carefully weaned off medications they may no longer need. Pharmacists play a key role in assessing patients’ medications and working collaboratively with the primary care provider to ensure that any changes are in the patient’s best interest. Faced with such a good news/bad news situation, residential care facilities have an important obligation to choose a pharmacy provider that is prepared to maximize the benefits and minimize any potential problems regarding patients’ overall health-
Helping people live with independence, dignity and in comfort since 1925. • Nursing • Physio and other therapies • Personal care and support • Homemaking
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50 HOSPITAL NEWS JUNE 2018
care. Sounds good, but just how do you do that? According to Chris Chiew, General Manager of Pharmacy for London Drugs, the first step is to select a pharmacy partner that is as committed to providing quality care as you are. The pharmacy should be willing to assign clinical pharmacists to your facility who will: • Provide on-site clinical services at an agreed upon schedule. • Provide comprehensive enhanced medication reviews. • Work collaboratively with facility staff to offer guidance and support when needed. • Work with the medication safety and advisory committee to develop and implement medication safety initiatives. • Provide education to facility staff and residents. • Immunize facility staff, residents, volunteers, and their families. • Assist in accreditation activities for the facility. • Provide pharmacy indicator reports (e.g., antipsychotic use, narcotic use, polypharmacy). www.hospitalnews.com
LONG-TERM CARE NEWS Chris Chiew’s Checklist for Selecting a Pharmacy Partner Chris Chiew offers the following checklist you can use to assess the services your pharmacy partner should provide:
IN ADDITION TO REGULARLY SCHEDULED GENERAL MEDICATION REVIEWS, YOUR PHARMACY PARTNER SHOULD HELP PREVENT DRUG RELATED PROBLEMS • In some jurisdictions, pharmacists can prescribe medications and provide documentation for primary care providers to ensure a collaborative approach to obtaining optimal health outcomes. In addition to regularly scheduled general medication reviews, your pharmacy partner should help prevent drug related problems. The pharmacist can pay particular attention to drugs that may cause special problems for the elderly and make recommendations for dosing based on kidney function. For example, certain classes of medications (e.g., antihistamines, antihypertensives, and diuretics) can cause
dizziness and lead to falls and hospitalization. A pharmacist can alert the staff to monitor blood pressure and implement changes to minimize falls. In other instances, a pharmacist may be able to suggest an alternative to the medication prescribed that may lower the risk of developing a serious adverse event. Choosing the right pharmacy partner is vital to ensuring the safety of your residents. It can also be important to your facility, as the relationship with the pharmacy and site staff is crucial to building a culture of trust and mutual respect. LC
Susan C. Jenkins is a freelance writer and editor specializing in medicine, pharmacy, and healthcare. She can be reached at email@example.com
Multiple regularly scheduled deliveries weekly plus emergency deliveries when necessary Medications dispensed in pouch packaging or card system Return and safe disposal of discontinued and expired medications Return and safe disposal of packaging with residents’ names Safe and accountable transportation of medications including narcotics 24/7, 365-day pharmacist consultation Electronic medication administration record Medication carts and pill crushers ndividualized resident billing Special authority alerts and renewals Pre-approval for non-benefit medications Automatic sending of not-in-pass medications (e.g., eye drops, insulin, puffers) to prevent stockpiling or shortage of doses Specialized wound, incontinence, and ostomy supplies billed to residents directly Compression stocking measured to fit Availability of best practice protocols (e.g., actively dying, constipation management, hypoglycemia management, warfarin dosing, safe disposal of sharps)
a leader in health continuing professional education Find out more about our interactive courses designed for health professionals working in home and long-term care: • ;`i\Zkfif]:Xi\:\ik`ÔZXk\`e:c`e`ZXc Leadership Other programs of interest: • K_\Nfle[:Xi\:\ik`ÔZXk\ • K_\8[mXeZ\[Nfle[:Xi\:\ik`ÔZXk\ • :\ik`ÔZXk\`e@MXe[@e]lj`feK_\iXgp • Fundamentals of Patient Navigation Contact us for more information: 416-736-2100 ext 22170 | firstname.lastname@example.org hlln.info.yorku.ca/open-programs www.hospitalnews.com
JUNE 2018 HOSPITAL NEWS 51
LONG-TERM CARE NEWS
Helping people with dementia ver half a million Canadians are living with dementia today and according to research, one in six people with the condition will go missing at some point during the course of their disease. We often use the term “wander” to describe how someone with dementia appears to walk around aimlessly. This suggests that there is no purpose to the person’s walking, which is a natural human activity.
52 HOSPITAL NEWS JUNE 2018
THE PERSON MOST LIKELY TO ASSIST A PERSON WITH DEMENTIA IS NOT AN EMERGENCY RESPONDER OR POLICE OFFICER, BUT A GOOD SAMARITAN IN THE COMMUNITY In fact, there are many reasons why a person with dementia may feel the need to walk. For example, they might be reliving a lifelong routine,
such as going to work. They might be feeling pain or discomfort and want to move around. They might be looking for a toilet or something
to drink. Or they may simply enjoy walking. However, they might also be lost, and are trying to find their way home. As dementia progresses, changes in the brain will impact a person’s ability to communicate and recognize their surroundings – even in familiar places. These changes over time can make a simple walk risky. If you’re a health-care professional caring for someone with dementia, you know that safety is integral to good care.
LONG-TERM CARE NEWS
ONE IN SIX PEOPLE WITH THE CONDITION WILL GO MISSING AT SOME POINT DURING THE COURSE OF THEIR DISEASE While you want the person in your care to be as independent as possible, you also don’t want them to become lost and potentially come into harm. Take the story of Betty Guschlbauer, who lives with dementia. Every day for the past 30 years, she’s walked the same way from her home in rural Ontario and back. There’s never been an issue, so her daughter, Eileen Crowston, has never been worried. Part of Betty’s walk takes her by a community centre. On one summer afternoon last year, the centre was hosting a party. The music drew Betty inside. But, once in the community centre, her routine was disrupted, and she became disoriented. Thankfully, someone at the centre noticed that Betty was wearing a MedicAlert Safely Home bracelet, an
ID and service that helps locate and return a person with dementia safely home. According to the Alzheimer Society, the person most likely to assist a person with dementia is not an emergency responder or police officer, but a good Samaritan in the community. The person at the centre checked the back of Betty’s bracelet, which is uniquely engraved with her medical conditions and MedicAlert’s 24/7 emergency hotline number. If someone goes missing, hotline specialists at MedicAlert can provide emergency responders and police with the person’s photo, physical description, emergency contacts and vital health information, helping to locate them more quickly. Specialists can also notify the missing per-
son’s caregivers or family to let them know their current situation and whereabouts. After the person at the centre called the emergency hotline number, the hotline specialist immediately patched the caller through to Eileen, who recalls the conversation. “She said, ‘Your mother is fine. She’s at our party. Could you come get her?’” says Eileen. When she arrived a few minutes later, Eileen found her mother dancing with a centre employee. “I tapped her partner on the shoulder, took her place and danced my mom out the door,” says Eileen. “Everyone clapped.” Consider MedicAlert Safely Home as part of your care plan for someone with dementia. To learn more about the service, please visit: www.alzheimer.ca/medicalertsafelyhome. MedicAlert Safely Home is offered jointly by MedicAlert Foundation Canada and the Alzheimer Society of H Canada. ■
4 ways to help people with dementia in your community With the warmer weather, more people are out and about enjoying the outdoors. Pay attention to those around you in your community or near your place of work. If you see someone in your community who is alone and appears confused or is dressed inappropriately for the weather, consider these four tips: • Approach them from the front and ask if you can help. •Smile! Speak slowly, clearly and use simple words. Tell them your name and why you’ve approached them. For example, “You seem like you are looking for something. Can I help you find it?” • Give them time to respond. Use gestures or repeat your question if necessary. • Ask if you can check their wrist. If you see a MedicAlert Safely Home bracelet, call the MedicAlert emergency hotline number engraved on the back immediately.
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LONG-TERM CARE NEWS
Ontario Stroke Evaluation Report 2018:
Stroke Care and Outcomes in Complex Continuing Care and Long-Term Care ach year, approximately 1,300 individuals in Ontario are admitted to longterm care (LTC) within 180 days of an acute care hospitalization for stroke or transient ischemic attack (TIA). To better understand the sociodemographic characteristics and burden of care for stroke survivors admitted to LTC, a new provincial report was released by CorHealth Ontario and the Institute for Clinical Evaluative Sciences, entitled: Ontario Stroke Evaluation Report 2018: Stroke Care and Outcomes in Complex Continuing Care and Long-Term Care. This report provides a review of data between 2010 and 2015, and delves into the nature and extent of rehabilitation therapy and stroke best practices available to stroke survivors in these settings. The intent of this report is to inform system planning, facilitate and advocate for system change, and identify opportunities for quality initiatives and research. Of stroke survivors residing in LTC, key findings for 2014/15 include the following: • 63.2% were women • 41.3% required extensive assistance with activities of daily living
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• 23.8% were at high risk for depression • 45.4% experienced bowel incontinence and/or 61.3% were reported to have bladder incontinence • 20.3% had severe cognitive impairment • 38.6% were considered to be socially engaged • 31.9% were admitted to inpatient rehabilitation prior to admission to LTC (an increase from 21.5% in 2010/11) • 35.4% did not receive any core therapies (i.e. physiotherapy, occupational therapy and speech-language pathology) and no stroke survivors received all three core rehabili-
tation therapies. Given that time spent in therapist-supervised core rehabilitation is calculated over a 7-day period, the median number of minutes of physiotherapy received per day was 6.4. Only negligible amounts of occupational therapy and speech-language therapy services were provided. • 11.4% received nursing restorative care programming (a decrease from 28.5% in 2010/11) • 25.5% experienced a fall • 6.3% diagnosed with atrial fibrillation received anticoagulant medi-
Illustration Above: Hall RE, Tee A, Khan F, McCormack D, Levi J, Verrilli S, Quant S, Donnelly B, Brown G, Campbell W, Brown P, Cristofaro K, Bayley MT. Ontario Stroke Evaluation Report 2018: Stroke Care and Outcomes in Complex Continuing Care and Long-Term Care. Toronto, ON: Institute for Clinical Evaluative Sciences/CorHealth Ontario; 2018. www.hospitalnews.com
LONG-TERM CARE NEWS
cation within 90-days of discharge from acute care • 18.1% died within 6 months of admission to LTC following their acute stroke or TIA. Also of note were the low health-related quality of life scores (mean = 0.37 out of 1) and the proportion of stroke survivors in LTC over 85 years of age, which increased from 36.1 to 40.8 per cent over the five-year period. Conclusions from the report specific to LTC are outlined below: 1. Stroke survivors in LTC settings have high care needs requiring extensive assistance with activities of daily living. Their low degree of social engagement and poor health-related quality of life are concerning. 2. Rehabilitation for stroke survivors in LTC is almost exclusively physiotherapy. The time spent in rehabilitation therapy and recreation therapy per day is minimal, and access to physiotherapy and nursing restorative care in LTC has declined over time.
STROKE SURVIVORS IN LTC SETTINGS HAVE HIGH CARE NEEDS REQUIRING EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING The low health-related quality of life scores may be attributed to the limited rehabilitation, nursing restorative care and recreation therapy, and the prevalence of depression and pain. 3. Defining the role of LTC in the stroke recovery trajectory will become more imperative as the shifting demographic is predicted to result in an increasing number of LTC admissions and increased stress on the overall health care system. This report also outlines the following recommendations specific to LTC which address changes at the system, regional and facility level: 1. Limited provision of rehabilitation to stroke survivors in LTC warrants review of resource allocation/care models for rehabilitation therapy
and nursing restorative care programming to inform an appropriate model for this setting. 2. Regional Stroke Network Community and LTC Coordinators should advance stroke best practices and LTC staff education by: • Leveraging existing stroke care resources (e.g. Taking Action for Optimal Community and LongTerm Stroke Care©, Stroke Care Plans for LTC, etc.), existing technology (learning management systems, software solutions) and partnering with stakeholders such as the RNAO LTC Best Practice Coordinators. • Supporting specialized training of LTC staff in secondary stroke prevention and highly prevalent
post stroke complications such as urinary incontinence, fall prevention, pain management, and post stroke depression. • Supporting LTC facilities in modifying care planning libraries to include best practice care interventions as outlined in the Stroke Care Plans for LTC (e.g., integrate the Stroke Care Plans into care planning libraries where gaps are identified). • Collaborating with LTC facilities to sustain current efforts and explore further innovations in fall prevention strategies and programs to promote safe mobility. The LTC representative from your Regional Stroke Network is available to provide further information and to support quality initiatives aimed at enhancing best practice stroke care provided to residents of Ontario LTC Homes. To access this representative within your area, please email CorHealth Ontario at firstname.lastname@example.org. LC
Submitted by Community & LTC Coordinators of the Ontario Regional Stroke Networks.
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IVIG: Panacea or pricey placebo? By Dr. Janice Mann hen most of us think of donating blood or receiving a transfusion, we tend to think of the transfer of red blood cells that carry oxygen in our blood. If we lose too much blood during surgery or injury, or can’t make enough blood due to illness, the red blood cells are replaced by a transfusion. While this type of transfusion is the most common, there are other parts of the blood that can be transfused as well – including the white blood cells (that fight infections), platelets (which help your blood to clot), and serum (the liquid part of your blood). Found within the blood serum are different proteins, including antibodies. Our bodies make antibodies to fight infections – different antibodies recognize different infections, and we make thousands of them throughout our lives. Sometimes it’s these antibodies that are needed and are transfused. But unlike red blood cell transfusions, thousands of donors are needed to create the blood product known as immune globulin (IG). Since it is usually given by intravenous, or IV, infusion (that is, through a vein) the product is often called IVIG. In Canada, Canadian Blood Services and Héma-Québec are able, through voluntary blood donors, to supply the individual blood components (such as red blood cells) needed for transfusions. But because blood plasma products like IVIG require thousands of donors, Canada must purchase IVIG and other blood plasma products from commercial manufacturers in the US, where blood donors are paid for giving blood. Canadian Blood Services supplies IVIG to hospitals at no charge, and each dose of IVIG can cost between $550 and $2,200 per child and between $2,000 and $8,000 per adult. The global demand for products like
56 HOSPITAL NEWS JUNE 2018
IVIG is high, and since Canada is unable to produce enough of its own products, we are potentially at risk for shortages and disruptions in supply in the future. To add to the uncertainty of our continued supply of IVIG, our demand for blood plasma products also continues to increase. In fact, Canada is one of the highest consumers per capita of IVIG in the world, and between 1998 and 2006, Canada’s use of IVIG more than doubled at a cost of $196.1 million. But what are we using all of this IVIG to treat? IVIG can be used if your body, for whatever reason, isn’t producing enough of its own antibodies, and you need antibodies from others to be able to fight infections and stay healthy. IVIG may also be used to treat inflammation or to manage conditions
that can cause your immune system to go awry and attack parts of your own body like your platelets or your nerves. In Canada, IVIG is approved to treat six conditions that fall into these categories. They include primary immune deficiency, immune thrombocytopenic purpura, secondary immune deficiency states, chronic inflammatory demyelinating polyneuropathy, Guillain-Barré Syndrome, and multifocal motor neuropathy. Although IVIG is used to treat these approved conditions, their treatment may not be why our use of IVIG is so high. It may actually be the “off-label” use of IVIG – using IVIG to treat other conditions that it isn’t officially approved by Health Canada to treat – that is contributing to our high and increasing use of the product. IVIG has been used to treat a wide variety of
other illnesses, including neurological conditions, blood conditions, autoimmune or inflammatory conditions, skin conditions, and recurrent miscarriage. But does IVIG actually work to treat or improve all of these different conditions? When the need arises for answers to an important question such as this, the health care community turns to CADTH – an independent agency that finds, assesses, and summarizes the research on drugs and medical devices. CADTH searched for medical studies that would help to answer questions about the role of IVIG in the treatment of off-label conditions, then appraised and summarized the evidence so that it could be used by clinicians and other decision-makers in the health care system. When CADTH looked at all of the evidence for a variety of different neurological conditions, the studies in general claim that IVIG treatment for neurological conditions is promising, but compelling evidence that IVIG works to improve most of these conditions is lacking at this time. For example, the results for epilepsy were mixed – meaning some studies find a benefit with IVIG treatment while others do not. But IVIG is no better than placebo (no active treatment) for Alzheimer’s or post-polio syndrome. However, evidence suggests that IVIG may be better than plasma exchange for the treatment of pediatric Guillain-Barré Syndrome, and IVIG is shown to be more effective than placebo for the treatment of multiple sclerosis in adults. Looking at the evidence for using IVIG to treat different conditions of the blood, CADTH found that there wasn’t a lot of evidence. For example there was no evidence on off-label hematological conditions such as aplastic anemia, autoimmune neutropenia, www.hospitalnews.com
hyperhemolysis after transfusion, and acquired hemophilia. That means we don’t know whether IVIG is effective to treat these conditions. A limited amount of evidence was found for blood conditions affecting a fetus or newborn. Overall, the evidence on the effectiveness of off-label use of IVIG for these specific conditions compared with other treatment options was mixed. When CADTH looked at the evidence for using IVIG to treat autoimmune diseases, the evidence indicated that off-label use of IVIG may be effective in some autoimmune disease but not in others. For example, IVIG improves outcomes for patients with systemic lupus erythematosus, and it improves cardiac outcomes in infants of mothers with antiphospholipid syndrome during pregnancy. However limited evidence does not show a benefit with IVIG for dermatomyositis, myasthenia gravis, polymyositis, Kawasaki disease, Sydenham’s chorea, or cardiac
UNLIKE RED BLOOD CELL TRANSFUSIONS, THOUSANDS OF DONORS ARE NEEDED TO CREATE THE BLOOD PRODUCT KNOWN AS IMMUNE GLOBULIN (IG). SINCE IT IS USUALLY GIVEN BY INTRAVENOUS, OR IV, INFUSION (THAT IS, THROUGH A VEIN) THE PRODUCT IS OFTEN CALLED IVIG complications of acute rheumatic fever. Overall, there is limited evidence to suggest that off-label IVIG is clinically effective for the treatment of autoimmune diseases and more evidence is needed. CADTH also looked for evidence on whether IVIG is effective to treat dermatological conditions such as Stevens-Johnson Syndrome, toxic epidermal necrolysis, polymyositis, dermatomyositis, bullous pemphigoid, and systemic sclerosis. In general, evidence on IVIG use for dermatological conditions is scarce and the studies are
Dr. Janice Mann MD is a Knowledge Mobilization Officer at CADTH.
small. Some studies suggest a possible benefit of IVIG treatment for some skin conditions, but more evidence is needed to understand whether IVIG is helpful for these patients. When CADTH looked at the evidence to see if IVIG can improve the chances of a live birth in women who have experienced repeated miscarriage, the results were unclear. Some studies find no difference in live birth rates with IVIG treatment compared with placebo or other treatments. But other studies do find a difference, with significant improvements in rates of
live birth with IVIG. This suggests that larger, well-conducted studies are needed to better understand the effectiveness of IVIG treatment in women who have had repeated miscarriages. The range of conditions that can be treated with IVIG – both those that are approved and those considered off-label – is vast. Our increasing use of this blood plasma product coupled with our dependency on out-of-country suppliers is concerning. By better understanding whether IVIG is effective in the treatment of these conditions, we can make decisions that help to ensure this valuable resource is being used in the best possible way. Evidence from CADTH helps to do just that. If you’d like more information on IVIG from CADTH, you can find it at: www.cadth.ca/IVIG. You can also follow CADTH on Twitter @CADTH_ ACMTS or speak to CADTH Implementation Support Team member in H your region. ■
New cafe is run for and by patients By Kelly Spence
fter much anticipation, thanks to the generous community donations to the Royal Ottawa Foundation, the Brockville Mental Health Centre officially opened a café run for and by the patients just last month. The River Café was made possible for the benefit of the forensic treatment patients and staff at the Brockville Mental Health Centre.
THIS CAFÉ WILL PROVIDE PATIENTS IN THIS PROGRAM THE OPPORTUNITY FOR THE DEVELOPMENT OF COMPETITIVE EMPLOYMENT SKILLS IN PREPARATION FOR COMMUNITY REINTEGRATION The Café was a way for The Royal Ottawa Foundation and its donors to give back to the Brockville staff and their patients. It is funded entirely by those generous donors, and seeing the café open its doors is a proud moment for the Foundation because of the rewards it will give those at the Brockville Mental Health Centre. “Initiatives like The River Café are very important to our donors because they see a direct and immediate reward to our patients and staff. Vocational skills are being created as are social skills. This is a great project which we’re proud to support,” says Mitchell Bellman, President and CEO, Royal Ottawa Foundation. What makes The River Café unique is that it is operated entirely by patients who are part of the Vocational and Occupational Therapy Program. This café will provide patients in this program the opportunity for the de-
Celebrating the opening of The River Café at Brockville Mental Health Centre. velopment of competitive employment skills in preparation for community reintegration. By supporting the ongoing patient programming around vocational training, patients who work at the café will learn and develop important social and business skills. “The River Café is a program that evolved based on a need expressed by patients and staff of BMHC,” says Brian Merkley, Director of Patient Care Services, Forensic Treatment Unit and one of the leads on the project. “We have collaborated with patients
and staff to create a program with benefits that are three-fold: The River Café offers a positive space that promotes social integration in a casual setting; The River Café promotes a sense of empowerment among patients as they now have the opportunity to make their own food choices, and practice essential life skills such as money management; and finally, The River Café provides an opportunity for development and practice of vocational skills in preparation for competitive employment in the community.”
This project has been in development since 2016 and aims to provide a dedicated space that will allow both patients and staff the opportunity to socialize together in a more casual setting. Prior to the creation of the café, patients and staff had no space dedicated to socializing together. The River Café will be open from Monday to Friday for two hours a day during lunch, with an opportunity for increased growth as resources become available. Continued on page 60
Kelly Spence is a PR intern, the Royal Ottawa Foundation for Mental Health. 58 HOSPITAL NEWS JUNE 2018
NEWS Noel Macdonald has been a volunteer at BC Women’s Hospital + Health Centre for over a decade.
Volunteer provides unique service for
grieving patients By Holly Tran olunteers are an important part of our organization and hospital; they contribute to greatly impacting our patients’ experiences. One of our volunteers, Noel Macdonald, has volunteered at BC Women’s Hospital + Health Centre for nearly a decade and provides quite a unique service for our patients and their families. Noel was a full time volunteer outreach worker in Vancouver’s Downtown Eastside for almost a decade before he started volunteering at BC Women’s, and his involvement in the community also included portrait photography. On one occasion, one of the families Noel was working with at the shelter asked if he would take baby photos for them at BC Women’s Fir Square Complex Care unit, where the family was having their baby. “I immediately fell in love with the moms and the Fir Square team,” says Noel. “That was eight years and 500 babies ago.” Noel shoots maternity portraits throughout the course of a mom’s pregnancy, and he would also follow up with portraits of the mom, baby and extended families. Occasionally,
he would follow Fir families into the community to do more portraits as the family grows. Three years ago, a social worker at BC Women’s asked Noel if he would take photos for a family that was experiencing a loss. This began his volunteer work as a demise photographer. The photos that Noel takes hold significance to our patients and their families. For the moms on Fir whom are struggling with substance and/or alcohol use, the photos bring them pride and joy of becoming a new mother giving them validation. “They deserve to be acknowledged and respected for the incredibly difficult task of facing their disease and getting treated at Fir,” says Noel. “The women also need to be recognized as moms and their love for their baby needs to be seen.” With demise photography, families come to cherish the final moments that are captured of their loss and the space these photos provide gives an outlet for families to focus their grief as part of their healing. The intimate nature of these photo shoots develops a unique connection between Noel and the families. “I find myself drawn to working in
WITH DEMISE PHOTOGRAPHY, FAMILIES COME TO CHERISH THE FINAL MOMENTS THAT ARE CAPTURED OF THEIR LOSS AND THE SPACE THESE PHOTOS PROVIDE GIVES AN OUTLET FOR FAMILIES TO FOCUS THEIR GRIEF AS PART OF THEIR HEALING the rewarding, challenging and vital space of supporting families that find themselves in an unbelievable situation,” says Noel. “I have somehow been able to work around death and dying in a compassionate, caring and productive way. Part of what keeps me working is the amazing relationship I have developed with
the nurses, doctors, social workers, respiratory therapists and chaplains supporting families (and each other) in this important work.” The motivation that keeps Noel volunteering besides the relationships he’s developed is that the saying is true: doing good work makes you H feel good. ■
Holly Tran is a Communications Officer at BC Women’s Hospital + Health Centre. www.hospitalnews.com
JUNE 2018 HOSPITAL NEWS 59
New cafe Continued from page 58
Nurse practitioner, Noelle, checks patient, Russell, in the RESSCU centre.
The right care in the right place at the right time By Elise Copps amilton Health Sciences is making sure cancer patients get what they need, when they need it – care that addresses their unique wishes as a person, not just their immediate problems as a patient. They’ve created a new program with this specific goal in mind. It’s called RESSCU – Rapid Evaluation and Symptom Support Cancer Unit. The nurse practitioner-led service, based at Juravinski Hospital and Cancer Centre, gives people direct access to a highly trained team to manage their symptoms and the side effects of their cancer treatment.
“It’s one stop with staff who have the knowledge and skills to care for these patients and their unique needs,” says Angela Djuric Paulin, who led the team behind the project’s implementation. “It’s well integrated with our cancer clinics, so there’s a sense of familiarity and more personalized care.” For Russell Crooks, who recently finished chemo and radiation, it’s a lifeline when he’s feeling very unwell. “The nurses are super in the RESSCU centre.” Tailored care allows more people to get the treatment they need in the unit, rather than being admitted to the
hospital. It also gives them an alternative to visiting the emergency department for symptoms like nausea and pain. These factors can lead to better health and reduce hospital gridlock. The majority of people seen during RESSCU’s pilot phase were treated and discharged home. Within 48 hours, they get a follow up phone call to check on their symptoms. They say RESSCU has improved their experience and given them more confidence in the healthcare system. Plans are in place to improve and expand RESSCU so more cancer patients can benefit from this innovative H model. ■
“We have collaborated with patients and staff to create a multi-faceted program that offers a positive space for socialization, promotes a sense of empowerment by offering the opportunity for choices and practice of life skills, and allows for development and practice of vocational skills to prepare patients for competitive employment in the community,” says Julie Basiliadis, O.T. Reg. (Ont.), another project lead. “When I first heard about the River Café program I thought it was a good thing,” says Trevor, one of the patients at Brockville Mental Health Centre who will be working in The River Café. “When they handed out the applications on the unit I applied right away, because I knew it would give me work experience and something to do while I am here. I liked the training we went through and I learned a lot. At first, I was nervous with doing it because I didn’t think I would be any good at it. But now I am comfortable with working in the café, with working with people. I really like it. This program helps me to focus on something constructive to do and it gives me something to look forward to. Maybe one day I will be able to get work in the community again. The café is an important part in helping me prepare for the community.” The patients working at the café are behind the food provided at the café as they produce all food served there, which gives clients the opportunity to eat healthy, and is overseen by a dietician who helps patients with the creation of the café’s menu. Additionally, The River Café provides the forensic photography program a space to showcase their work, which hangs on the walls of the café. The River Café – named by the patients – is located in a secure part of the Brockville Mental Health Centre and is for staff and patients’ use only – the café is not accessible by the public. During the launch however, staff and patients welcomed the public to the special café opening, including the H hospital’s board of trustees. ■
Elise Copps is a public relations specialist at Hamilton Health Sciences. 60 HOSPITAL NEWS JUNE 2018
Considering the ethics of
personalized medicine By Andria Bianchi ersonalized medicine is commonly defined as a type of medical care that is managed in accordance with one’s personal genome. The idea is that if a person’s genetic variants are known, then clinicians will be able to more accurately determine what types of treatment(s) will improve health outcomes. Some examples of personalized medicine are “using targeted therapies to treat specific types of cancer cells, such as human epidermal growth factor receptor 2 (HER2)-positive breast cancer cells, or using tumor market testing to help diagnose cancer.” Personalized medicine is consequentialist and individualistic – its primary purpose is to determine the best medical consequence for particular individuals. The hope is that people will ultimately be able to pursue treatments that will be effective for them and they will not need to undergo unnecessary ones; this type of medicine eliminates a “one size fits all” approach. Personalized medicine is typically discussed in a positive light. With an increasing amount of health technologies being developed to treat health conditions, knowing more information about a person’s genetic make-up can help when it comes to creating a care plan. Alongside the many benefits of personalized medicine, however, some ethical concerns have also been discussed in the academic literature. It is
IN ADDITION TO THESE POSITIVE CONSIDERATIONS, ONE OF THE MAIN ETHICAL QUESTIONS/CONCERNS IS WHETHER PERSONALIZED MEDICINE IS JUST (AND THE PRINCIPLE OF JUSTICE IS ONE OF THE PRIMARY ETHICAL PRINCIPLES IN BIOETHICS) important to familiarize ourselves with the ethical benefits and potential challenges to ensure that we develop ethically defensible processes and policies. One of the primary ethical strengths of personalized medicine is, of course, that people will be able to receive treatments that are more likely to benefit them – this responds to the clinical duty to do the most amount of benefit (and the least amount of harm). Also, in a clinical setting that uses personalized medicine, patients may more immediately trust their clinicians’ recommendations since they will be developed based on their specific genetic variants. Furthermore, personalized medicine may be helpful from an economic viability standpoint. Many resources are wasted (from a financial perspective) by giving people treatments that do not work; it would be more economically beneficial to only fund and provide people with treatments that are likely to be effective. Relatedly, people who undergo various treatments to try to improve and/ or cure their medical condition(s) may
require multiple hospital stays, which is costly. In addition to these positive considerations, one of the main ethical questions/concerns is whether personalized medicine is just (and the principle of justice is one of the primary ethical principles in bioethics). Will everyone around the globe be able to afford and access diagnostic tests and necessary treatments? Is it possible that only the wealthiest people and/or nations will be able to afford certain tests and medicines, thereby increasing the inequality that exists amongst certain groups? Another concern surrounds that of privacy and confidentiality. Who will be able to access personal information and what are the potential consequences? Moreover, is it possible that clinical teams, insurance companies, etc. may eventually require people to undergo genetic testing? If so, then this may influence a person’s right to make autonomous decisions about the type of testing and care that they need, specifically because they
would need to undergo such testing in order to be insured/receive medical treatment. The ethics of incidental findings pose another challenge of personalized medicine. If a person undergoes a medical test in the spirit of receiving personalized care, and unexpected information about their health condition/overall health becomes known, then what are our ethical obligations? Should a person always have a choice to learn about and/or to remain ignorant about incidental findings? What should we do if an incidental finding could potentially influence a person’s family member(s)? Finally, as noted by Nicolls et al., personalized medicine is based on genetic characteristics that are internal to an individual – external influences (e.g. poverty, environmental factors) are not considered, even though they may have a significant impact on a person’s health. Perhaps we should initially focus our energy and resources on improving these external influences/health-related factors more than internal ones… The ethical benefits of personalized medicine may, from many perspectives, outweigh potential vulnerabilities. As our health technologies and approaches to medicine continue to advance and change, however, it is important to be cognizant of, reflect upon, and mitigate potential H concerns. ■
Andria Bianchi is a Bioethicist at the University Health Network, a PhD Candidate at the University of Waterloo, and a board member of the Canadian Bioethics Society. www.hospitalnews.com
JUNE 2018 HOSPITAL NEWS 61
Volunteer care clowns bring laughter to Hamilton General Hospital n a children’s hospital, you don’t have to look far to discover activities and entertainment. But for adults staying in the hospital, it can be harder to find distractions from procedures, tests, and waiting. Enter Dottie and Polly, a pair of jokesters on a mission to spread warmth and laughter in the hospital. They say laughter is the best medicine. That’s why a visit from Hamilton Health Sciences’ (HHS) therapeutic hospital clowns can make our patients feel just a bit better. Developed in 2002, the care clown program aims to bring warmth and happiness to patients, families and health care providers at Hamilton General Hospital. “Children receive so much attention and stimulation as an inpatient to while away their time. Adults, on the other hand, must find ways to make their stay bearable, and so began the humour cart and therapeutic care clown program,” says Lorraine McGrattan, manager of Volunteer Resources, who believes the program’s impact on patients, visitors, and staff is immeasurable. Laughter is known to decrease stress and relax the body, triggering the release of endorphins, the chemical that makes you feel happy. Dressed in bright colours and armed with compassion, care clowns Dottie and Polly Pigtails visit Hamilton General Hospital about twice a month. They carry props like stuffed flowers to bring spring fever into the hospital room, oversized scissors for pretend haircuts and manicures, “boo boo” stickers to place on hurt areas, and a giant needle during flu season to administer the “flu shot.” Dottie says there is nothing more rewarding than seeing a sad face turn happy. “The reactions are almost always positive. People tell me I made their day just by walking through the halls, even when I haven’t said anything yet.” Suited in her funky polka dot attire and bright pink hair, one of
Dottie and Pollie visit with a patient and brighten his day.
DEVELOPED IN 2002, THE CARE CLOWN PROGRAM AIMS TO BRING WARMTH AND HAPPINESS TO PATIENTS, FAMILIES AND HEALTH CARE PROVIDERS AT HAMILTON GENERAL HOSPITAL her favourite things to do is to sing, which usually gets the patient joining in. She sings popular songs like “You are my sunshine” during a patient’s stay and “Hit the road, Jack” upon discharge. Dottie has been volunteering with HHS since 2013, while Polly, a former HHS Pharmacy Technician, has been volunteering since 2006. Polly recounts standout moments as a care clown, like when she was invited into a room when an agitated patient had to be transferred to another hospital by paramedics. “The patient happily transferred to the stretcher. We waved
and sang goodbye. His wife was so very grateful. One year later we met her, and she reminded us of the stressful moment and her heart felt gratitude.” Polly says it’s a gift to raise people’s spirits and help them smile, even through the most trying times. Quiet waiting rooms transform and fill with laughter and conversation when they drop by. “We feel truly blessed to have shared this moment with them. Laughter does help heal and is a definite stress buster for patients, staff and visitors.” But between stickers and songs, their best trick of all is simply their car-
ing personalities. “These two ladies are beautiful inside and out. I love watching the reactions they get as they walk through the halls,” says Nancy Hayes, coordinator for the Volunteer Resources department. Volunteer resources organizes volunteers across HHS hospitals, including those who dedicate their time to helping visitors find their way around (known as our GPS – Guiding People Services), those who work in the gift shops, and other positions like care clowns. On a recruitment poster that hangs in the Volunteer Resources office is a quote from Patch Adams (you may be familiar with the physician that used humour to treat patients from the 1998 comedy starring Robin Williams). The poster reads: “It’s fun to do and a jubilant thrill to help others.” “It is certainly inspirational,” H says Polly. ■
This article was submitted by Hamilton Health Sciences. 62 HOSPITAL NEWS JUNE 2018
A therapeutic approach Sudbury CNS uses psychotherapy to help clients with mental health challenges By Daniel Punch ate one evening in 2003, Stacey Roles had a conversation with a client that shaped the future of her nursing career. She was 22 years old and less than a year out of nursing school. During a shift at the Regional Mental Health Centre in London, she was working with a woman who was diagnosed with depression, but wasn’t responding to her medication. Roles had worked hard over the previous days to develop a rapport with the woman using motivational interviewing. She spent some extra time with her that evening, and after speaking for a while, the woman started to open up about all the symptoms of psychosis she had been hiding from other care providers. “It all just poured out,” Roles recalls.
PSYCHOTHERAPY IS EXTREMELY IMPORTANT TO THE ROLE OF THE RN Thanks to that late-night conversation, she and her colleagues were able to reassess the woman’s condition and adjust her medication. “If I hadn’t built that (relationship) with her, (the truth) may never have come out,” she says. The experience solidified the value of building therapeutic relationships with clients, Roles says. It also reinforced that she was on the right path, after years of being unsure. During nursing school at Sudbury’s Cambrian College, she kept waiting for a particular nursing specialty to jump out at her. Nothing had, but profound experiences like this one early in her career made it clear that mental health was it. “I just loved (mental health nursing),” she says. “I knew it was my passion.”
A few months after her experience in London, Roles moved back to her hometown of Sudbury, where she has lived for most of her life. From that point on, she says every career move she made was driven by a desire to do more for clients with mental health challenges. Toward that end, she expanded her knowledge and leadership skills by earning her bachelor’s degree in Laurentian University’s post-RN program in 2005. Then in 2012, she zeroed in on her specialty by completing her master’s degree in nursing and becoming a clinical nurse specialist (CNS) – an RN with a master’s or PhD and extensive clinical experience in a specialty area. She also studied cognitive behavioural therapy (CBT) and other forms of psychotherapy so she could have even more meaningful interactions with her clients. Now 36, Roles’ CV reads like that of someone much later in their career. She currently works as a CNS in the mental health program at Health Sciences North; an adjunct professor for Laurentian’s school of nursing; and a faculty member in the Northern Ontario School of Medicine’s (NOSM) psychiatry program. She is also a certified CBT trainer and supervisor, and runs her own practice (centerforcbt.ca). To top it off, she recently started work on her PhD in human studies, which will focus on best practices for treating people with borderline personality disorder. It all adds up to a busy schedule, and her efforts have not gone unnoticed in her community. In November, Roles was recognized by Northern Ontario Business as one of Sudbury’s 40 Under Forty – an award handed out to influential young leaders in the city. “I was kind of embarrassed, but honoured,” she says humbly. “It’s nice to be acknowledged for doing good in your community.”
It means a lot to her that the nomination came from colleagues, who wanted to recognize her efforts to promote CBT throughout northern Ontario. As a CBT practitioner, trainer and researcher, she has become a vocal advocate for the popular form of psychotherapy. She says it can make a major difference for sufferers of depression, anxiety, post traumatic stress disorder (PTSD), and other mental health challenges.
And Roles says nurses must play a significant role in bringing CBT to underserviced communities in the north. Whether they realize it or not, she says RNs are already practising psychotherapy in all roles and sectors, and must continue to do so. “Psychotherapy is extremely important to the role of the RN,” she says. “We have nurses working in every area (of Ontario) and they have the foundation, H skills and ability... to help people.” ■
This article was originally published in the November/December 2017 issue of Registered Nurse Journal, the bi-monthly publication of the Registered Nurses’ Association of Ontario (RNAO). Daniel Punch is former communications officer for RNAO
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Registered Nurses Emergency Services Program: Emergency Location: Oshawa, Bowmanville, Ajax and Port Perry https://www.lakeridgehealth.on.ca/en/index.asp Status: Full-Time, Temporary Full Time and Regular Part-Time; Day/Night, 12 hour schedule Wage Scale: $32.21 - $46.11 per hour Lakeridge Health is currently looking for enthusiastic and patient-focused Registered Nurses to join our Emergency team. In this position you will have the opportunity to use your extensive knowledge and expertise to help us develop, implement and maintain innovative Emergency Department practices that will meet the current and future needs of Lakeridge Health. QUALIFICATIONS • Registration with the College of Nurses of • Proven EKG interpretation, cardiac monitoring, trauma nursing, and patient Ontario (in good standing); assessment skills (test); • Current B.C.L.S.; • I.V. Certiﬁed and Deﬁbrillation Certiﬁed; • Demonstrated commitment to main• Commitment to successfully complete taining Reﬂective Practice Standards as CNA Emergency Nursing Certiﬁcation outlined by the CON; (ENC(C); • Recent signiﬁcant Emergency/Critical • Critical Care/ER/PALS/TNCC Certiﬁcate Care experience: paediatric experience; preferred; • Successful completion of coronary care • B.Sc.N and ACLS preferred; courses from an approved institution; Please see the complete list of duties and qualiﬁcations on our website posting as per link listed below. Lakeridge Health thanks all applicants, however, only those selected for an interview will be contacted. If you are qualiﬁed for the above position please apply online; https://careers.lakeridgehealth.on.ca/erecruit/VacancyDetail.aspx?VacancyUID=000000022211 and/or send resume directly to firstname.lastname@example.org Lakeridge Health is one of Ontario’s largest community hospitals, serving people across Durham Region and beyond. With ﬁve hospital sites and four Emergency programs Lakeridge Health is driven by an ongoing commitment to continually improving services we provide to ensure we meet the needs of our community.
JUNE 2018 HOSPITAL NEWS 63
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Focus: Personalized Medicine, Volunteers and Fundraising, Health Promotion and Canadian Society of Hospital Pharmacists Supplement.
Published on May 30, 2018
Focus: Personalized Medicine, Volunteers and Fundraising, Health Promotion and Canadian Society of Hospital Pharmacists Supplement.