Hospital News October 2018 by Hospital News

Inside: From the CEO’s Desk | Evidence Matters | Safe Medication | Nursing Pulse | Careers

October 2018 Edition

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Contents October 2018 Edition

IN THIS ISSUE:

First Canadian face transplant

12 ▲ Cover story: Can we harness social media to save lives?

▲ Brainwave tracking technology in treatment of mental health challenges

8 ▲ Reducing obesity stigma bias

COLUMNS

Editor’s Note ....................4 In brief .............................6 Safe medication ............26 Ethics .............................28 From the CEO’s desk .....34

▲ Accessibility in mental health Nursing pulse ................46 treatment

Hospital News’ Marketplace

Evidence matters ...........35

Public health

must become a priority I

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Kristie Jones

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By Trevor Hancock and Art Eggleton n 2010, Canada’s Ministers of Health stated in a Declaration on Prevention and Promotion that “the promotion of health and the prevention of disease, disability and injury are a priority and necessary to the sustainability of the health system.” So you would think that public health would be a clear priority in Canada’s health care system. However, Canada’s governments have not acted in accordance with those fine words. Public health is the only part of the health care system that is wholly concerned with preventing death, disease and injury. While most apparent in infectious disease control, it plays a leading role in the fight against tobacco, chronic diseases, obesity, injury, substance abuse, addictions and mental disorders. Not only does public health improve the health of the population, it is one of the best ways to sustain our publicly-funded health care system. On average in 2015, the health care system consumed 37 per cent of provincial program expenditures, a proportion that all provinces are struggling to contain. Because as health care funding’s share of the budget increases, it squeezes other sectors whose contributions to health and well-being are just as important: housing, education, social services and others.

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There is only so much the provinces can do to reduce the cost of health care through efficiencies before they have to reduce services and access. But there is a better way: reduce the burden of disease, which is the work of public health. In addition, there are significant economic benefits from prevention, not only from avoided health care costs but in avoided loss of production, income and tax revenue. Public health is being weakened across Canada. As it is, it receives only three to four per cent of health care funding, and in some provinces and health authorities, much less. Public health funding in Nova Scotia is among the lowest in the country, at 1.5 per cent of health care spending in 2010/11. Quebec’s regional public health units were hit by severe budget cuts of 33 per cent in 2015, while the British Columbia Auditor General reported last year that while all the care sectors within the system had increases in funding between 2012/13 and 2015/16, public health funding actually decreased. It is not only a matter of funding. Recent editorials and commentaries in the Canadian Journal of Public Health have pointed to other problems, including downgrading the status of public health within governments and health authorities, eroding the independence of Medical Officers of Health and limiting the scope of public health.

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President Brainstorm Communications & Creations

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Dr. Cory Ross, B.A., MS.C., DC, CSM (OXON), MBA, CHE Vice President, Academic George Brown College, Toronto, ON

Continued on page 5 Dr. Trevor Hancock is a retired Professor of Public Health at the University of Victoria. Senator Eggleton is Chair of the Senate Standing Committee on Social Affairs, Science, and Technology. ASSOCIATE PARTNERS:

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Monthly Focus: Technology And Innovation In Healthcare / Patient Experience/Pharmacology: Digital health advancements and new technology in healthcare. Programs and initiatives focused on enhancing the patient experience and family centred care. An examination of safe and effective use of medications in hospitals and clinical pharmacology.

Monthly Focus: Year In Review/Future Of Healthcare/ Accreditation/Hospital Performance Indicators: Overview of advancements and trends in healthcare in 2018 and a look ahead at trends and advancements in health care for 2019. An examination of how hospitals are improving the quality of services through accreditation. Overview of health system performance based on hospitals performance indicators and successful initiatives hospitals have undertaken to measure and improve performance.

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

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NEWS

Public health Continued from page 4

For example, the New Brunswick government recently dismantled the Office of the Chief Medical Officer of Health, moving some 70 of the 110 staff out of the Ministry of Health and spreading them across three different ministries. This prompted a former CMOH for New Brunswick to label these changes “a recipe for disaster,” but despite this and other strong expressions of concern from public health leaders across Canada, the New Brunswick government has gone ahead with its changes.

PUBLIC HEALTH IS BEING WEAKENED ACROSS CANADA.

Meanwhile, nationally, the Chief Public Health Officer for Canada was downgraded by the Harper government from leading the Public Health Agency of Canada to being little more than an advisor to a President. Inexplicably the Liberal government – which established the Agency in 2004 – has failed to reverse this change in status and authority. So significant is the crisis facing public health that last year, Canada’s Chief Medical Officers of Health – who rarely speak out publicly against the provincial and territorial governments for whom they work – wrote in the Canadian Medical Association Journal imploring (their word) “health ministers to reaffirm commitment to the principles outlined in the declaration.” Public health cannot fulfill its vitally important role with one hand tied behind its back. Our health care system and the health of our population depend upon a strong public health sector. Canada’s governments need to make public health a H priority. ■ www.hospitalnews.com

ACCESS Health:

Closing the gap in access to care

By Michael Green outine visits to the doctor’s office would be a distant memory if more Canadians could access their health information and health services online. Imagine how convenient it would be to renew prescriptions online. Imagine how relieved you would feel if, shortly after taking a blood test, you could view your results online and see that everything was okay. Imagine how much time and money you would save if you could have a virtual visit with your doctor instead of taking time off work for an in-person visit. And imagine how all of this could improve the efficiency and sustainability of our health system. According to a new study conducted for Canada Health Infoway (Infoway), Canadians who can currently access these services are collectively saving up to $150 million a year by avoiding taking time off work, travel and other costs associated with visiting a doctor’s office. Our health system is saving an additional $134 million a year because patients who can access their health information and connect with their doctor electronically avoid unnecessary phone calls and in-person visits and have fewer trips to the emergency department. The value and other benefits are significant and will become much greater as we close the gap between Canadians’ desire and their ability to access personal health information and health services online. According to our most recent survey of Canadians, only 22 per cent have access to their health information online, while 73 per cent do not have access and would like it. Forty-one per cent want access to virtual visits – the ability to talk with their health care providers by video – while only six per cent can do so. Canadians have told us that online access to their health information and digitally-enabled health services makes them feel more confident in managing their health condition, improves the

timeliness of the care they receive, and results in better communication with their care teams. So how do we ensure that Canadians can access their health information and services in the same way they access their financial services – online, at their convenience, and with assurance that the highest standards of privacy and security are in place? Infoway’s bold new ACCESS Health program is harnessing the power of Canada’s technology sector and driving development of new digital tools and e-services to make health care more accessible. Delegates to the Infoway Partnership Conference (Nov. 13-14 in Montreal) will have an opportunity to learn more about ACCESS Health. Infoway’s Lynne Zucker will lead a panel that will consider a case for creating ACCESS Gateway to tackle Canadian health care challenges at a national scale. The panel will also explore the role of private-public sector cooperation to make it happen. There will also be concurrent sessions about the technical aspects of Gateway, includ-

ing consent and trust frameworks and the critical factors needed for success. Concurrent sessions on PrescribeIT™ will focus on how Canada’s national e-prescribing service is contributing to better medication management, medication reconciliation and patient adherence. Infoway’s Bobbi Reinholdt will also lead a session to discuss the role PrescribeIT™ can play in the fight against the opioid crisis in Canada. You won’t want to miss this conference, so learn more at https://infoway-inforoute.ca/en/what-we-do/partnership-conference and register today. We are excited about the promise of ACCESS Health. It will strengthen overall access to care, improve the patient experience by helping people access their health information online and connect to the services they need, and give providers digital tools to help them deliver the best care possible. With a little imagination and a strong collective effort, we can create a health system that offers Canadians the convenience and peace of mind they’re asking for, while delivering sigH nificant value to our health system. ■

Michael Green is President and CEO of Canada Health Infoway. Connect with him on Twitter @MGreenonHealth.

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IN BRIEF

Over half of Canadians consider anxiety and depression ‘epidemic’ O

ver half of Canadians (53%) consider anxiety and depression to be ‘epidemic’ in Canada, with that perception spiking amongst younger people, according to a new survey commissioned by the Canadian Mental Health Association (CMHA). Fifty-nine per cent of 18 to 34-yearolds consider anxiety and depression to be ‘epidemic’ in Canada, followed closely by addiction (56%) and ahead of physical illnesses such as cancer (50%), heart disease and stroke (34%), diabetes (31%) and HIV/ AIDS (13%). The survey accompanies a national CMHA policy paper, Mental Health in the Balance: Ending the Health Care Disparity in Canada, which calls for new legislation to address unmet mental health needs and bring mental health care into balance with physical health care.

BY 2020, DEPRESSION WILL BE THE LEADING CAUSE OF DISEASE IN CANADA.

Eighty-five per cent of Canadians say mental health services are among the most underfunded services in our health-care system – and the majority agree (86%) that the Government of Canada should fund mental health at the same level as physical health. Despite recent unprecedented mental health funding commitments made by the federal government, over 1.6 million Canadians report unmet mental health-care needs each year. Worldwide, mental illness accounts for about 23 per cent of the total disease burden, yet Canada dedicates only 7.2 per cent of its health-care budget to mental health. And, the

need for mental health services and supports is growing. By 2020, depression will be the leading cause of disease in Canada. “What we outline in our policy paper is that righting this balance is about more than just the balance sheet,” explains Dr. Smith. “The Mental Health Parity Act we are advocating for is not just about increasing funding for mental health services, but also improving coordination, treatment, research and access and making better choices about how best to spend health-care dollars effectively.” Lengthy wait times are a problem, in part, because there has been a chron-

ic underfunding of community-based mental health services and a reliance on intensive, high-cost services like psychiatrists and hospitals. Up to 80 per cent of Canadians rely on their family physicians to meet their mental health care needs, but those services are limited. Evidence-based health care provided by addiction counselors, psychologists, social workers and specialized peer support workers is the foundation of the mental health response in other G7 countries, but these services are not guaranteed through our public system. In addition to improving quality of life and health outcomes, mental health promotion, mental illness prevention and early intervention can reduce the burden on our health-care system. A recent study on the treatment of depression estimated that every dollar spent on publicly funded Continued on page 7

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IN BRIEF

Where people live before hospitalization important for discharge planning Epidemic Continued from page 6 psychological services would save two dollars for the health system. To make sure that those who need services and supports get them, new legislation must also address stigma and discrimination – in the healthcare system, amongst practitioners and at the individual level – and improve access for those who are marginalized. The imbalance in research funding of mental health vis-à-vis physical health, should also be addressed. The Canadian Institutes of Health Research (CIHR), for instance, spends only 4.3 per cent of its annual research budget on mental health. Canada needs sustained research investment in mental health to spur innovation, better translate scientific knowledge into practice and develop therapies that are appropriate, effective and that promote treatment acceptance H for people with mental illnesses. ■

discharge planning orty per cent of older adults who leave hospital are discharged to home care or a long-term care facility, which, combined with where they lived before hospitalization, affects their risk of readmission, found a study published in CMAJ (Canadian Medical Association Journal). These data are important for both health care professionals and policy-makers to improve discharge planning for patients and to reduce readmissions. “The information from this study will contribute to a better understanding of the extent to which complicated transitions to and from hospital influence readmission among older adults, which is essential for system planning, performance measurement, and the targeting and testing of

Progress in net cancer survival in Canada over 20 years ust under half of all Canadians are expected to be diagnosed with cancer during their lifetime, while approximately one-quarter of Canadians are expected to die from this disease. Cancer survival estimates, which provide a measure of disease severity and prognosis, are critical to the monitoring of progress in cancer outcomes when examined over time. A new study released in Statistics Canada’s Health Reports provides estimates of net survival – where the cancer of interest is hypothetically the only possible cause of death – for 30 of the most commonly diagnosed cancers. These estimates are also compared over 20 years. The study makes use of a new analytical file, which links data from the Canadian Cancer Registry with death information.

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From 2012 to 2014, five-year net survival ranged from 98 per cent for thyroid cancer to 7 per cent for mesothelioma. Five-year net survival was particularly high for cancers of the testis (97%) and prostate (93%), but especially low for cancers of the pancreas (8%), esophagus (15%), lung and bronchus (19%), liver (19%) and brain (21%), as well as for acute myeloid leukemia (21%). Between 1992 to 1994 and 2012 to 2014, improvements in five-year age standardized net survival were greatest for chronic myeloid leukemia (+23.9 percentage points). Increases exceeding 15.0 percentage points were also observed for non-Hodgkin lymphoma (+19.5), cancer of the small intestine (+17.4) and multiple myeloma (+16.9). In contrast, little to no improvement was observed for cancers of the anus, larynx, soft tissue or uterus, or H for mesothelioma. ■

interventions to improve transitions and reduce readmissions,” writes Dr. Andrea Gruneir, Department of Family Medicine, University of Alberta and ICES, with coauthors. While most research on readmissions focuses on people who are admitted to hospital from the community and who return to the community, this study considers the large number of older adults with more complex pathways across the system. The large study of 701,527 hospitalized adults over age 65 in Ontario found that 31.5 per cent of people were discharged to home care and 9.5 per cent to long-term care, with three per cent newly admitted to long-term care. More than half (53.5%) were women and 40 per cent had five or more chronic conditions. Almost every patient (98%) had visited a doctor at least once during the year before hospital admission, 331,168 (47%) had visited the emergency department and 72,536 (10%) had been admitted. The authors state that the study “shows that fundamental shortcom-

ings in the health system’s ability to meet older adults’ needs, particularly those with dementia, manifest as frequent use of acute care, including readmissions, prolonged hospital stays with extended alternate levels of care periods and ‘non-acute’ reasons for hospital admission.” People who were discharged with home care were the most likely to be readmitted, and when readmitted, 19 per cent were there for two or more weeks and nearly 20 per cent were designated as alternate level of care (ALC), the longest of any group in the study. Conversely, people who were discharged to long-term care (as a new admission) were the least likely to be readmitted, but their first hospital stay was most often for dementia. More than 80 per cent were in hospital for two or more weeks and were designated as ALC, which means they no longer need acute hospital care but can’t be discharged as the appropriate level of care required is not available in another H setting. ■

Inhaled version of blood pressure drug shows promise in treating anxiety, pain n inhaled form of a high blood pressure medication has potential to treat certain types of anxiety as well as pain, according to a new study by the Centre for Addiction and Mental Health (CAMH). Anxiety disorders are usually treated with different types of medications, such as antidepressants, and psychotherapy. Amiloride is a medication offering a new approach, as a short-acting nasal spray that could be used to prevent an anxiety attack. “Inhaled amiloride may prove to have benefits for panic disorder, which is typically characterized by spells of shortness of breath and fear, when people feel anxiety levels rising,” says lead author Dr. Marco Battaglia, Associate Chief of Child and Youth Psy-

chiatry and Clinician Scientist in the Campbell Family Mental Health Research Institute at CAMH. The study was based on understanding the key physiological changes in brain functioning that are linked to anxiety and pain sensitivity. The researchers then tested a molecule, amiloride, which targets this functioning. Amiloride was inhaled so that it could immediately access the brain. The study showed that it reduced the physical respiratory signs of anxiety and pain in a preclinical model of illness. This therapeutic effect didn’t occur when amiloride was administered in the body, as it didn’t cross the blood-brain barrier and did not reach the brain. Results were published in H the Journal of Psychopharmacology. ■ OCTOBER 2018 HOSPITAL NEWS 7

NEWS

Brainwave

tracking technology to treat challenging mental health conditions

By Vivian Sum magine being able to lower the impact of unhealthy thoughts through visualization. Technological advances are bringing healthcare one step closer to managing mental health conditions that are difficult to treat with medications using videogame-like computer software. Vancouver Coastal Health Research Institute scientist Dr. Carl Laird Birmingham uses a piece of brain imaging technology called Low Resolution Electromagnetic Tomography (LORETA) to treat mental health conditions such as anorexia nervosa. Anorexia is a mental health-related eating disorder that manifests itself through food restriction and a fear of gaining weight. The LORETA neurofeedback technology tracks brainwaves – electrical pulses from neurons in the brain – through wires that run from a computer to sensors placed on a patient’s scalp. In his latest research – published in the journal Eating and Weight Disorders in March 2018 – Birmingham used LORETA to compare brain activity in anorexia nervosa patients and control subjects. His research found that when patients with anorexia were shown images of high-calorie food, the fear centres in their brains were activated in ways similar to when someone without anorexia is shown images of spiders and other frightening things. There is presently no cure for anorexia, and the condition is highly difficult to treat. Around one per cent of women and less than one per cent of men in Canada will develop anorexia during their lifetime with onset typically occurring in the teenage years, notes Birmingham. Of these patients, about 50 per cent will never get better. The condition is usually best treated during its earlier stages – within six months to one year. Current treatments include supplementing patients’

This computer monitor displays images of a patient’s brainwave activity using LORETA technology. Brainwaves are tracked using electrodes embedded in a cap that is placed on a patient’s scalp.

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diets with zinc, prescription medications and psychological therapy. However, 40 per cent of patients who receive treatment relapse within one year. That figure rises to 70 per cent within two years. The LORETA brainwave scanning technology displays the neural activity inside of a patient’s brain as a series of upwards and downwards lines on a computer screen. These lines represent how areas of the brain react to what a patient is thinking and feeling. In Birmingham’s study, when a patient with anorexia is shown an image of high-calorie food, the lines in parts of the brain that react to fearful situations rise. To treat this, Birmingham asks patients to concentrate on lowering that line. When it reaches or goes below a threshold, a song of the patient’s choosing plays. This technique is called operant conditioning. “The brain is constantly listening to what is happening around you. Operant conditioning is basically teaching the brain that to receive the reward of hearing a song the patient enjoys, it needs to adjust its electrical pulses to a certain level. It is like receiving points for completing a task in a video game.” Operant conditioning could be applied to other brain-related illnesses and traumas, as well. After being struck by a truck while cycling in 1998, Birmingham began using LORETA to treat his brain injury and the post-traumatic stress disorder he developed as a result of the accident. At his Vancouver clinic, he also treats others with head traumas and mental health disorders. “Many psychological disorders have not seen as many treatment advances as most other medical conditions,” says Birmingham. “We need to do more to explore novel treatment options to work towards improved H outcomes for patients.” ■

Vivian Sum is a Communications Specialist at Vancouver Coastal Health Research Institute. www.hospitalnews.com

NEWS

Photos by Doug Nicholson

Fifth graders visited Sunnybrook in August to judge a competition where summer research students use plain language to explain their research to make it accessible to the public.

Fifth graders form judging panel for research event at Sunnybrook By Alexis Dobranowski ome summer research students at Sunnybrook had to explain their work to some small and inquisitive young judges. As part of the Sunnybrook Research Institute Summer Student Research Day, summer students were invited to submit a simple summary of their work in a way the public – even kids – would understand. More than 40 projects were submitted. Five finalists competed for a cash prize. Eleven youngsters took part in judging the finalists, who presented complicated research about stroke, opening clogged arteries, knowledge translation, repairing nerve cells and heart surgery using simple language. “If you touch the middle of your chest, there’s a hard bony part called the sternum. In order to open up the chest and reach the heart, doctors need to cut the sternum in half and separate it,” explained Apurva Dixit during her presentation. “After the surgeon is done the heart repair, it’s important that they put the sternum back together properly and this is what my research looks at.”

Apurva went on to explain that her summer research looked at wire versus cable ties when it comes to re-fastening the sternum. She was comparing which method has better outcomes – fewer infections and less pain for patients. The young students didn’t let the summer researchers off easy. They put them on the hot seat and asked lots of questions to make sure things made sense. Jennifer Hutter, a 4th year kinesiology student at McMaster University, was awarded first place for her presentation about stroke and exercise. “For people with stroke, regular exercise is really important. Scientists have found that it can help them move better, get stronger, and even make it less likely that they’ll have a stroke again in the future,” Jennifer told the youngsters. “But there’s a problem: even though doctors tell their patients that it’s very important to exercise, some of them still don’t get active.” Jennifer’s work, which she conducted this summer at St. John’s Re-

hab, involved meeting with patients and asking them about their lives and exercise habits, and then the patients wore a FitBit for a week to track their exercise. Jennifer then looked at what things made it harder for people to get exercise – in hopes of finding ways to make that easier in the future (for example, a family exercise class to help people who don’t exercise because they have many people to take care of). She said it was exciting to see the 5th graders so engaged with the research. “I was also surprised by how much the experience helped me understand my research,” Jennifer said. “At first, I just wanted to communicate it in a way that other people could understand, but as I worked through the various drafts of my presentation, I was forced to think about the broader implications of my research and it allowed me to understand how important it truly is.” She said it’s important to be able to explain your research in a way even kids can understand because the research being done at Sunnybrook af-

fects everyone – not just adults and certainly not just the scientists conducting it. “With the amount of time, energy and funding invested in the research we do, it’s important that the general public understands what exactly is coming out of it,” Jennifer says. In addition to the presentations, the young students also visited Sunnybrook’s research floor, where they met with scientists who are coding special goggles to allow doctors see 3D heart models based on CT and MRI images to help them during heart procedures. The initiative is part of Sunnybrook’s ongoing effort to involve the community in all aspects of the health-care setting and bring research to the public. Congratulations to Jennifer and the other finalists: Apurva Dixit, Daphne Walford, Gursharan Sohi and Humna Noman. And a big thank you to all our judges: Sarah, Neil, Oliver, Hannah, Yumi, Elizabeth, Declan, Nathanael, Jacqueline, Quintin and H Stephanie. ■

Alexis Dobranowski is a Communications Advisor at Sunnybrook Health Sciences Centre. 10 HOSPITAL NEWS OCTOBER 2018

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NEWS

Greater mental health support for patients in rehab By Natalie Chung-Sayers he was a pedestrian victim of a car’s collision. After a critical period in emergency then undergoing surgeries to repair broken bones and torn ligaments, she continued her recovery in acute care. A few weeks later she is in a rehabilitation facility. The slower pace helps lessen the intensity of it all. She is moving well, though a sense of hopelessness persists. She no longer participates in therapy and remains withdrawn despite her family’s encouragement. What can be done for her? “Many patients are recovering from life-changing events. In rehab, they are regaining their mobility and independence, perhaps after experiencing a trauma, severe burns or an acute stroke, but these events can also have an impact on mental health,” says Dr. Larry Robinson, chief, Rehabilitation Services, St. John’s Rehab Program, Sunnybrook. “We recognized a need and an opportunity in our rehab setting to provide more comprehensive mental health support to those who may need it.” Psychiatrists Dr. Matthew Boyle and Dr. Rosalie Steinberg of Sunnybrook’s Hurvitz Brain Sciences Program are becoming integrated into inpatient rehab teams at St. John’s Rehab, and are supporting patients through psychiatric consultations and follow-up mental health care. Psychiatry is not typically embedded in rehab settings in Canada, and St. John’s Rehab is at the forefront of this model. Studies have shown that having active and early involvement of psychiatry services in medical settings can help reduce the length of stay. “Comprehensive biopsychosocial treatment plans can help patients

Mental Health Team in Rehab Hospitalist

Psychiatrist

Physiatrist

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Phychologist

Nurse Physiotherapist

Dietitian

Pharmacist

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Mental Health Team in Rehab

PSYCHIATRY IS NOT TYPICALLY EMBEDDED IN REHAB SETTINGS IN CANADA, AND ST. JOHN’S REHAB IS AT THE FOREFRONT OF THIS MODEL. progress on their path towards recovery in rehab,” says Dr. Boyle. “These patients may experience mental health conditions such as depression, adjustment disorder, post-traumatic stress disorder, anxiety, dementia, delirium,” he says. “They can also experience exacerbation of existing mental illness secondary to medical issues,” adds Dr. Steinberg. Drs. Steinberg and Boyle see about 30 per cent of inpatients at St. John’s Rehab and are gathering data on the benefits of these support services. In particular, they provide specialized mental health care to support patients with trauma or burns who are initially treated at the hospital’s Bayview site. “Often we can continue treatment plans begun in acute care while collaborating with the rehab teams on

adjustments. When patients are ready to leave inpatient rehab, we provide continuity of care, either in follow-up to our outpatient clinics, or through referrals to community resources,” says Dr. Steinberg. “Psychiatry is not as black and white as other areas of medicine. Over the extended rehab stay, our diagnosis of a patient may change, our understanding of the patient’s presentation may change, and often patients come in with more than one issue. Sometimes a diagnosis will become clear only after acute care has been delivered. By definition, you need two weeks of symptoms to diagnose depression, and a month of symptoms to determine post-traumatic stress disorder. As we typically have a longer length of stay at St. John’s Rehab, it allows us to

provide more longitudinal care for patients in starting treatment interventions,” says Dr. Boyle. The psychiatrists work with the rehab teams to enhance their understanding of potential mental health issues and to help them identify patients who may need support. As care collaborators, Drs. Boyle and Steinberg also help build therapeutic alliances with the teams to allow for more consistency especially when caring for patients with existing personality and behavioural challenges. “Also key to a patient’s recovery is the involvement of their family,” adds Dr. Boyle. Natasha agrees. She is the daughter of a patient at St. John’s Rehab who sought mental health support. “It is very important for family to be supportive – to be there to ask the questions, and to be the advocate for their loved one so they don’t become confused or anxious. It’s also important for patients to be very self-motivated and to advocate for themselves, especially when family members can’t be there.” “Mental health is a private matter for many. People may not want to talk about it, and respect and discretion are critical to allow conversations to happen. If needed, patients and family members should feel free to ask for more privacy, and opt to move the discussion to an area they feel is suitable,” she adds. Drs. Boyle and Steinberg are also working to build educational capacity in medical psychiatry by training residents in the provision of psychiatric care in rehab, and will soon pilot a new rotation for non-psychiatry H residents. ■

Natalie Chung-Sayers is a Communications Advisor at Sunnybrook Health Sciences Centre. www.hospitalnews.com

OCTOBER 2018 HOSPITAL NEWS 11

NEWS

First Canadian face transplant a success n what constitutes a first in Canada, a team of surgeons from the Hôpital Maisonneuve-Rosemont (CIUSSS de l’Est-de-l’Île-de-Montréal), led by the distinguished plastic surgeon Dr. Daniel Borsuk (also University of Montréal), have announced that they have successfully completed a face transplant. The operation was carried out in collaboration with Transplant Québec in May 2018 at the Hôpital Maisonneuve-Rosemont on a disfigured 64-year-old man, the world’s oldest recipient of a face transplant. The operation, which lasted 30 hours, required the expertise of multiple specialists, and the exceptional collaboration of more than one hundred professionals, including doctors, nurses, and many other personnel. The transplant was made possible by means of an organ donation thanks to the work of Transplant Québec, along with the permission and incredible empathy of the donor’s family. “This delicate operation is the result of years of concerted, meticulous work by an incredible team and the incredible bravery and cooperation of the patient and his family. Through the combination of science, technology, engineering and art we attempted to build on the knowledge and experience of the pioneers in the field to perform the best facial transplant possible for our patient,” says Dr. Borsuk, who also teaches at the Université de Montréal. Four months after the procedure, the transplant recipient is doing well. He has fully recovered the ability to breathe without a tracheostomy, and has begun to chew with his new jaws, smell through his new nose, and speak with his new lips.

Top: The patient before and after the face transplant. Bottom: A profile view of the patient before and after transplant. 12 HOSPITAL NEWS OCTOBER 2018

www.hospitalnews.com

NEWS

FOUR MONTHS AFTER THE PROCEDURE, THE TRANSPLANT RECIPIENT IS DOING WELL. Seven years ago, the man was severely disfigured by an accidental gun shot. Since then, he has been living in constant pain and experienced a poor quality of life, despite the five reconstructive surgeries he underwent. The face transplant offered the patient the only option to restore his two jaws, facial muscles and nerves, teeth, lips, and nose. “The CIUSSS is proud to have reconstructive surgery excellence within its walls, a discipline which gives the hope of returning to a normal life to many patients,” says Yvan Gendron, CIUSSS-EMTL President and CEO The patient had to live with a tracheostomy (opening in the trachea). His ability to breathe, sleep, eat and speak were highly compromised.

Moreover, social interactions and public appearances proved to be challenging and resulted in the patient choosing to remain indoors and isolated. This natural extrovert had hoped for years to be able to once again have a normal life and be in contact with others. It took the unrelenting work of an entire team to achieve this medical and scientific feat, unprecedented in Canada. The surgical team was comprised of nine surgeons: In plastic surgery, Dr. Daniel Borsuk, Dr. André Chollet, Dr. Dominique Tremblay, Dr. Jenny Lin, Dr. Charles Guertin and Dr. Michelle Tardif; in ENT, Dr. Tareck Ayad and Dr. Akram Rahal; and in maxillofacial surgery, Dr. Jean Poirier.

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Such a surgery requires not months, but years of meticulous preparation, for both the surgeons, who honed their expertise beforehand, and the patient, who underwent many indepth physical and psychological examinations and procedures. This type of surgery also requires significant ethical and logistic preparation on the donation side, as well as having to deal with consent issues with the donor’s family. “We wanted to ensure that the recipient would take on what was going to be a major change in his existence in the best physical possible health, armed with all the necessary information and psychological support,” says Dr. Borsuk. “We will continue to support the patient so he can completely adapt to his life post surgery.”

This complex procedure remains extremely rare globally. Since 2005, some forty face transplants have been performed around the world. The transplant done by Dr. Borsuk and his associates at Hôpital Maisonneuve-Rosemont is not only the country’s first, but also a first for Commonwealth countries. Despite the complexity of the procedure and rehabilitation, the procedure is in fact relatively inexpensive for the public system, when compared to the multiple surgeries that would have been required to attempt to reconstruct this type of injury. More fundamentally however, it makes it possible for the individuals who undergo facial vascularized composite allotransplantation to enjoy a more productive and H normal life. ■

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Improving care for people with

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complex mental health needs By Steven Gallagher new and innovative program at Niagara Health is enhancing care and access to services for people with complex mental health needs. The Wellness Recovery Integrated Comprehensive Care program, which was launched in April, helps people to fully understand their mental health needs and to identify and develop strategies to improve their wellness. A goal of the program is to reduce readmissions to hospital and visits to an Emergency Department for non-urgent mental health issues. “We’re trying to help people enhance their coping skills, their knowledge and their abilities so that they’re able to problem solve in the community, rather than going to the Emergency Department as an immediate response

for help with non-urgent issues,” says Robert Cosby, Clinical Manager of Niagara Health’s Outpatient Mental Health and Addictions Program. Non-urgent visits to the Emergency Department that could be managed in the community include a person wanting to talk to someone; an individual looking for a healthcare provider or someone who is having difficultly navigating the healthcare system. People referred to the program include individuals with a mental health diagnosis, such as severe depression, bipolar or schizophrenia, and people who are at high risk of readmission to a mental health inpatient unit or who frequently visit Emergency Departments. Here’s how the program works: Participants, who must be 18 years or older, are connected with a team of

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healthcare professionals from Niagara Health who work collaboratively with them to identify their mental health needs and to ensure they are receiving the best possible care. The healthcare team includes registered nurses, social workers, occupational therapists, nurse practitioners and a psychiatrist.

A GOAL OF THE PROGRAM IS TO REDUCE READMISSIONS TO HOSPITAL AND VISITS TO AN EMERGENCY DEPARTMENT FOR NON-URGENT MENTAL HEALTH ISSUES. Participants meet with members of the team at the hospital or in the community to receive care and create an individualized recovery plan based on their needs. The program is “very person-centred,” says Robert. “Participants are identifying what they need in their journey of wellness and recovery,” he says. “You have to

work really closely with people to help guide them and to see that they do have the resiliency, the strength and the knowledge. With this program, we’re enhancing that.” Participants also have access to other therapy programs at Niagara Health, and they are connected with services in the community, such as Niagara’s Crisis Outreach and Support Team and Quest Community Health Centre. Social Worker Robin Crown, the Clinical Lead of the program, is impressed with the new model of care and the impact it will have on people’s lives. “I’m excited we can be creative, flexible and help people with what they need to make a difference in their life.” Niagara Health also has an Integrated Comprehensive Care Program for people with chronic obstructive pulmonary disease and congestive heart failure. Since its launch two years ago, the program has helped hundreds of people manage their symptoms at home. The program has decreased length of stay in hospital by three days and reduced readmissions and unanticipated Emergency Department and Urgent Care visits for participants by more H than 10 per cent. ■

Steven Gallagher is a Communications Specialist at Niagara Health. 14 HOSPITAL NEWS OCTOBER 2018

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Improving organizational culture to support patient safety By Dr. Tom Lloyd hile there has been a great deal written about organizational culture recently, it is still difficult to define and a complex concept for leaders to tackle. Yet there is evidence that it is a critical issue that must be addressed to improve patient safety. A flawed organizational culture in a healthcare context adversely affects teamwork and communication, and consequently increases risk and impacts safety. The Joint Commission has estimated 80 per cent of serious medical errors involved miscommunication between caregivers during

transfer of care. A hospital culture felt to be unsupportive, unfair and blame-focused will often engender disruptive behaviour, which is also known to have a negative impact on patient safety as it leads to ineffective care and poorer clinical outcomes.

A LEARNING ENVIRONMENT Conversely, substantial improvement to hospital culture can successfully improve organizational outcomes and patient safety. The challenge for institutional leaders is how to bring

Organizational Programs to Improve Patient Safety Improvement to hospital culture can substantially improve patient safety. Saegis has developed three professional development programs for hospital leaders and healthcare teams that are offered on-site at hospitals and healthcare institutions. Just Culture is an innovative professional development program that will help engender a culture of learning that can improve patient safety. Leaders will learn how to reinforce behaviour that supports and protects the organization’s values as well as improve systems, reduce negative outcomes and improve team morale. The Strategies for Managing Unprofessional Behaviour workshop helps leaders recognize and address unprofessional behaviour within their healthcare teams. The workshop includes the development of personal and institutional improvement plans to ensure the program has a lasting impact. Communicating Unexpected Outcomes is a workshop that will improve transparency with patients and families after unexpected clinical outcomes, including those resulting from errors in care. Healthcare teams who participate in this program will learn to disclose clinical errors with empathy and respect, as well as to improve their support of other team members in these often-difficult circumstances. Hospital and healthcare leaders interested in learning more can CALL 1-833-435-9979 or EMAIL info@saegis.solutions

16 HOSPITAL NEWS OCTOBER 2018

THE JOINT COMMISSION HAS ESTIMATED 80 PER CENT OF SERIOUS MEDICAL ERRORS INVOLVED MISCOMMUNICATION BETWEEN CAREGIVERS DURING TRANSFER OF CARE. it about. It has been reported that to achieve cultural improvement, organizations need to foster a learning environment wherein assessment of errors and incidents is consistent, transparent and not just punitive. This requires sustained and visible support by management for teams, as well as promotion of psychological security and the ability to safely speak up when individuals feel something is wrong. The concept of installing a “just culture” has for many years, in a number of industries, been seen as an effective way to meet this need. It combines law, human factor science and system design, and focuses on shared accountability between team members and leaders, while also taking into account the interplay between behavioural choice and system design.

INSTILLING A JUST CULTURE One approach to instilling a more just culture is through an investment in training. For example, one program, Just Culture Certification by Minneapolis-based solutions firm Outcome Engenuity, has been very successful worldwide in turning around flawed cultures in high-risk, safety-driven industries, such as aviation and manufacturing as well as healthcare. The program aims to lead organizations away from judging events on the severity of the outcome to understand-

ing the root causes and learning from the error. Through a mix of online learning and in-person course work, it is intended to provide knowledge and tools for leaders and teams to establish a more open and fair culture. One key tool of the program is the Just Culture Algorithm™, a decision-making tool for managers to determine consistent, appropriate and constructive responses to an incident or error. In Canada, the just culture concept appears to be gaining traction, and training is now more accessible due to a recent partnership between Outcome Engenuity and Saegis, a subsidiary of the Canadian Medical Protective Association (CMPA). Through this collaboration, Saegis now offers a range of Just Culture courses and programs onsite at hospitals across Canada.

INVESTING IN ORGANIZATIONAL CHANGE While programs like Just Culture are available to help hospitals engender positive change in their organizational cultures, the challenge for institutional leaders is to determine if they are an investment priority given the scarcities of time and budgets. Ideally, though, as more Canadian hospitals see tangible, positive results from programs like H Just Culture ■

Dr Tom Lloyd, LLM, MB ChB, MD, MRCS, MFFLM is Director, Saegis Safety Institute. www.hospitalnews.com

Hospital and healthcare team leaders: Organizational and cultural issues can impact team morale, put patients at risk and be costly.

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MARKETPLACE SPOTLIGHT Behaviourist Candace Vilhan (left) and Registered Dietitian Jennifer Brown work every day with patients who live with obesity, helping them to identify and overcome obesity stigma and bias.

How to recognize and reduce

obesity stigma and bias By Kathryn Young

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besity â&#x20AC;&#x201C; now considered a complex chronic disease similar to diabetes, high blood pressure and high cholesterol â&#x20AC;&#x201C; is a disease people â&#x20AC;&#x153;wear,â&#x20AC;? so theyâ&#x20AC;&#x2122;re subject to constant stigma and bias. â&#x20AC;&#x153;I often think that if I was an alcoholic, had diabetes or high blood pressure etc., people wouldnâ&#x20AC;&#x2122;t be able to see those conditions and then judge me for my perceived health status,â&#x20AC;? explains Candace Vilhan, a patient advocate as well as Behaviourist at The Ottawa Hospital Bariatric Centre of Excellence. Physical abuse, verbal taunts, and micro-aggressions such as eye rolls and tutt-tutting lead people living with obesity to experience many mental health issues, such as low self-esteem, anxiety, depression, social rejection, and suicidal ideation and acts. They are also less likely to seek medical advice. Stigma and bias come from all areas of society, including friends and family members, who are reported among the main sources of stigma, as well as health-care providers.

â&#x20AC;&#x153;I spent a long time listening to the criticism from others regarding my chronic disease, and feeling like a failure,â&#x20AC;? says Vilhan. â&#x20AC;&#x153;And I see this in my work with patients. If you have obesity, you are constantly appraising your environment and feeling blamed. Am I going to fit in that chair or be embarrassed? Is the doctor going to weigh me in an area where other people can hear my weight? Will I get chastised for not being active â&#x20AC;&#x2DC;enoughâ&#x20AC;&#x2122;? Are people staring at me and judging me? Many people living with obesity leave medical appointments feeling ashamed and are less likely to return for follow-up for fear of being judged or blamed because of their weight.â&#x20AC;? â&#x20AC;&#x153;Stigma and bias against people living with obesity has been a form of discrimination for years, but you canâ&#x20AC;&#x2122;t tell by looking at someone how healthy or happy they are,â&#x20AC;? says Jennifer Brown, Registered Dietitian with the Bariatric Centre of Excellence and a member of The Ottawa Hospital Dietitian Promotion and Advocacy Committee. Continued on page 20 www.hospitalnews.com

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Reduce obesity stigma Continued from page 18

“I UNDERSTAND WHAT IT FEELS LIKE TO BE BEATEN DOWN BY SHAME AND BLAME THAT OVERSIMPLIFIES THIS VERY COMPLEX DISEASE. I RECENTLY SAW A QUOTE THAT RESONATED: ‘IF SHAME AND BLAME FROM FRIENDS, FAMILY, THE MEDICAL COMMUNITY AND MYSELF HELPED TREAT OBESITY, I’D BE THE THINNEST PERSON EVER’.” one’s weight, body mass index, body shape or size.” Unfortunately, weight stigma and discrimination continue to rise, especially among health-care providers, according to several studies (Phelan, Rudd Center). However, the health-care team at the Bariatric Centre of Excellence provides a safe physical and mental health environment for patients. The centre has larger chairs, floor-mounted toilets, wider doorways, bariatric wheelchairs, scales that read higher weights, and larger blood pressure cuffs. The

“We need to accept and celebrate body diversity, including different shapes, sizes and weight.” Over the past decade, researchers and clinicians have started to understand the complexity of obesity, which is now defined as having excess body fat that impairs health. “We now know there are multiple factors that contribute to this chronic disease, including our genetics, physiology, biology, metabolism, social and physical environment, including food and physical activity,” explains Brown. “It is no longer solely based on some-

Stand up for mental health with CSMLS CSMLS has compiled a Mental Health Toolkit to provide individuals and organizations with the means to identify, monitor and implement change for the betterment of the medical laboratory profession. You and your organization do not stand alone in trying to work through mental health issues. Being overwhelmed by stress can affect your mental health. Stress is a universal concept that affects everyone. In small amounts, stress can help you get through tight deadlines, have a difficult conversation with your manager or motivate you to do homework or take a professional development course after a long day. Unfortunately, stress can become overwhelming, and there are occasions when we feel powerless to make changes within ourselves and our work environments. How can we empower ourselves against mental health issues? Enact change with CSMLS. The award-winning CSMLS Mental Health Toolkit can be a starting point for obtaining information on mental health issues that supports seeking services and treatment. It is also a resource for employers and organizations to support mental health programs that foster wellbeing and decrease ﬁscal expenditures.

What are the key principles of obesity management? 1. Obesity is a chronic disease that requires long-term management. 2. Obesity management is more than just reducing numbers on a scale— it’s about improving overall health and well-being over the long term. 3. An important part of obesity management is identifying and addressing root causes for weight gain and removing roadblocks. 4. Every individual defines success differently. 5. Work towards your “best” weight. Source: Obesity Canada

health-care team takes a non-judgemental, compassionate approach that is free of obesity bias. “One of my challenges is to establish trust with patients, because their previous encounters with health-care providers may not have been positive experiences,” Vilhan says. “As healthcare providers, we need to consider our own biases so we don’t inadvertently impact a patient who is already fearful of being judged based on past experience. We receive positive feedback from patients, who feel like they ‘fit’ in this space because it is more comfortable.” Patients who would like to be seen at the centre must have their doctor refer them through the Ontario Bariatric Network. Vilhan advocates for patients as a member of The Ottawa Hospital’s Patient and Family Advocacy Committee in obesity care as well as through Obesity Canada. “I do this advocacy work because I understand what it feels like to be beaten down by shame and blame that oversimplifies this very complex disease,” says Vilhan. “I recently saw a quote that resonated: ‘If

shame and blame from friends, family, the medical community and myself helped treat obesity, I’d be the thinnest person ever’.” Oct. 11 – World Obesity Day – marks an international campaign to end weight stigma and bias by supporting practical actions for people living with obesity. Everyone has a part to play – at work, at home and in our community. Here are the top four tips for healthcare providers and others to help end stigma and bias: 1. Use people-first language. Use “people living with obesity” or “you have obesity” rather than “obese people,” “the obese,” or “you are obese.” 2. Treat people living with obesity with the same level of respect and dignity as anyone else. 3. Be mindful of your bias. Negative comments, actions or behaviours towards someone’s weight is a form of bullying. 4. Avoid letting a person’s weight impede medical care, diagnosis or management. Not every medical isH sue is weight-related. ■

mentalhealth.csmls.org Kathryn Young is the Publications Officer at The Ottawa Hospital. 20 HOSPITAL NEWS OCTOBER 2018

www.hospitalnews.com

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Get involved in Canadian Patient Safety Week! anadian Patient Safety Week (CPSW) is a national, annual campaign to inspire extraordinary improvement in patient safety and quality. Working together, thousands of healthcare professionals, patients and families spread the message to Ask. Listen. Talk. to create a safer healthcare system. Canadian Patient Safety Week runs October 29 to November 2, 2018. This year, CPSW will focus on medication safety with the goal of reducing medication errors across Canada. Not All Meds Get Along encourages an open dialogue between patients and healthcare professionals by promoting each to seek medication reviews for at-risk populations and promoting the use of the 5 Questions to Ask About Your Medications. Medication errors should be taken seriously. Consider these facts: • An estimated 37 per cent of seniors in nine provinces received a prescription for a drug that should not be taken by this population. • Two out of three Canadians over the age of 65 take at least five different prescription medications. One out of four Canadians over the age of 65 take at least 10 different prescription medications. • In 2016, one in 143 Canadian seniors was hospitalized due to harmful effects of their medication. • Preventable medication hospitalizations cost over $140 million CDN in direct and indirect healthcare expenditures, with lost productivity, including time off work, adding $12 million CDN in costs. Globally, the cost associated with medication errors has been estimated at over $55 billion.

on five or more medications; those over 65 years of age; individuals with multiple caregivers, or using multiple pharmacies; people at risk of falls; individuals with chronic medical issues; and during transitions of care. Ask your healthcare professional or pharmacist for a medication review when you are having a new or existing prescription filled or if you are considering adding, removing or changing any non-prescription medications or supplements.

To reduce the risk of medication errors, medication reviews are specifically recommended for anyone

The goal of Canadian Patient Safety Week is to reduce medication errors by 50 per cent over the next five years.

The Canadian Patient Safety Institute is coordinating the World Health Organization’s Medication Without Harm campaign in Canada; Canadian Patient Safety Week supports this initiative. Much of the promotion of Canadian Patient Safety Week takes place digitally and on social media. Some activities planned for the week include online quizzes to test medication safety knowledge for both patients and providers; a medication safety webinar; a “caption this” comic challenge; a virtual screening and Twitter Talk event of “Falling Through the Cracks:

Greg’s Story”; and new episodes of the award-winning PATIENT podcast. Join the CPSW Medication Safety webinar on Monday, October 29th at 12:00 Noon EST. Details on the presentations and speakers are available on www.asklistentalk.ca and will be emailed to CPSW registered participants. The “Caption This” Comic Challenge is a fun way to get involved. Use the Not All Meds Get Along image and write a caption for the illustration. Post your entry on social media and tag the message with #AskListenTalk for the chance to win great prizes!

This article was submitted by the Canadian Patient Safety Institute 22 HOSPITAL NEWS OCTOBER 2018

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Accessible and barrier-free:

New Rapid Access Addictions Medicine Clinic By Ellen Samek ental Health and Addictions Services at Michael Garron Hospital (MGH) has a new addition: the Rapid Access Addictions Medicine (RAAM) Clinic. The clinic operates on Tuesdays and Fridays from 9 a.m. to 11 a.m. The RAAM Clinic welcome referrals but also allows patients to “walk-in” during clinic hours to provide accessible care for those seeking medical help with addictions and substance misuse.

The clinic opened in April 2018 as a joint project between the Emergency Department and the Toronto East Health Network Withdrawal Management Centre. The clinic offers short term medical treatment and counselling for all substance use disorders for adults. It aims to better integrate addiction care into the hospital and local primary care system as well as connect patients to longer term treatment. “Clients with substance misuse often end up in the emergency room be-

cause you can just walk in without an appointment,” says Wendy Fenomeno, the manager of the RAAM Clinic, Community Mental Health Services and Withdrawal Management Services. Wendy, who is a registered nurse, has always been passionate about mental health and addictions services. “For me it’s always been about helping the clients. They just speak to me, their strength of character, their courage but also their vulnerabilities,” says

Wendy. “I’ve always been angry with how society treats people who suffer with mental health and addictions issues.” The MGH RAAM Clinic team is made up of four physicians who work on rotation and two addictions counselors. Dr. Kate Lazier is one of those physicians. She also helped develop the RAAM Clinic. “In the ER we see so much addiction – overdoses, trauma, withdrawal, mental health issues and so on. Continued on page 27

CANADIAN PATIENT SAFETY WEEK RUNS OCTOBER 29 TO NOVEMBER 2, 2018. On Friday, November 2, at 12:00 Noon EST, a Twitter Talk event will take place: learn about Greg Price’s journey through the healthcare system that ended in his unexpected and tragic death, followed by a discussion moderated by the Price family. The film and discussion are intended to inspire positive change and improvement in the healthcare system, sure to resonate with healthcare providers and leaders, and will help create a platform for future dialogue. Follow @Patient_Safety and @GregsWings to learn more. The second season of the PATIENT podcast series explores patient safety through a non-fiction medical drama from the perspective of the patient. Three new episodes will be added to this series, focusing on medication safety. Listen to the first season of PA-

www.hospitalnews.com

TIENT podcasts at www.patientpodcastcanada.ca Free digital downloads and promotional packages are available to help you promote Canadian Patient Safety Week at your organization. Printable posters, social media images and slides for point of sale and TV screens are available at www.asklistentalk.ca. You can also order promotional tools such as pens, stickers, buttons, large-scale posters and medications lists and much more from the CPSW online store. How will your organization celebrate Canadian Patient Safety Week? For ideas, take a look at the Communications Toolkit and don’t forget to share your messages and pictures on social media using the hashtag #AskListenTalk. To register for Canadian Patient Safety Week, visit www.askH listentalk.ca ■

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Unique partnership brings mental health education to the community By Elise Copps amilton Health Sciences (HHS) staff are reaching into the community to help frontline workers support youth with mental health issues. This fall at HHS’ Ron Joyce Children’s Health Centre, Marlene Traficante

and Dr. Paulo Pires will offer their fourth workshop on youth mental health, geared specifically for frontline community service staff. The workshop began last year with a simple connection. Irene Heffernan, senior project manager with City of

PREPARING HEALTH-CARE LEADERS WHO CAN HARNESS DISRUPTIVE TECH This September, the labs and classrooms at Durham College welcome the first cohort of students in the Honours Bachelor of Health Care Technology Management (BHCTM) program. Developed in collaboration with subject matter experts and representatives from regional hospitals and health-care organizations, advocacy groups, non-profits and major medical equipment manufacturers, it is the first degree of its kind in Canada. The BHCTM addresses an identified need in the health-care sector for professionals with a diverse skill set that combines expertise in medical technology, life sciences and best practices for business. Graduates will deliver quality, cost-effective health care by keeping life-saving technologies available, effective and safe. An integration of technology, information and analytics in health care is underway on a global scale; its momentum is inescapable and potential for better care unlimited. Yet such unification is also causing health-care organizations to struggle. Disruptive medical technologies – AI-embedded medical technology in particular -- are game changers that will transform the sector. It only makes sense that in the most disruptive period in the history of health care a specialist should exist who can guide their organization through such transformation, ensuring it reaps all the benefits technology has to offer. This is the domain and role of the health-care technology manager and Durham College is thrilled to be part of the emergence of this entirely new discipline in health-care technology management.

24 HOSPITAL NEWS OCTOBER 2018

Hamilton’s Xperience Annex, was working with a number of organizations across Hamilton that deliver services to youth. Many of their clients are vulnerable and don’t have a strong support system. Many of them also have mental health challenges, including depression, anxiety and related substance abuse. Frontline staff in these organizations are well equipped to help youth navigate social services, but they don’t always have the knowledge and tools to support them in a mental health crisis. When HHS’ director of interprofessional development, John Parker, joined Xperience Annex’s Youth Steering Committee, he saw an opportunity to help. He connected Irene with HHS staff who specialize in youth mental health, and she saw a perfect opportunity to transfer their knowledge. Dr. Pires, a psychologist, and Marlene, a social worker, have been working in youth mental health for 16 years and 24 years, respectively. The pair knows how far basic knowledge about mental health can go in supporting youth in crisis. With Irene’s input, they developed a teaching plan to deliver a workshop that would provide frontline

youth community workers with tools they may need to help their clients. “Being able to respond appropriately when a youth comes to you with a problem can make a big difference for them,” says Marlene. “We aren’t teaching people how to be therapists, but we’re giving them a greater understanding of mental health issues so they can act as a support when needed.” The workshop covers a wide range of topics including factors that can contribute to mental health issues, signs of anxiety, low mood, and suicide risk, and strategies for coaching clients through difficult emotions. “When you can identify mental health issues and validate the experience of the youth, you start an important conversation,” Marlene adds. “Youth won’t always want to accept help, but when they feel validated, they will be more open to it. We teach frontline workers how to validate their clients’ emotions, which can lead to a conversation about how to solve the underlying problems.” For workshop attendees, learning how to start that conversation has been a game changer.

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“WE TEACH FRONTLINE WORKERS HOW TO VALIDATE THEIR CLIENTS’ EMOTIONS, WHICH CAN LEAD TO A CONVERSATION ABOUT HOW TO SOLVE THE UNDERLYING PROBLEMS.” Courtesy of AAMI.

“People who have attended this workshop have told us that learning to validate and then ask the client to take action has been really effective,” says Irene. Julia Verbitsky, an intensive community case manager with Wesley Urban Ministries who completed the workshop, says it emphasized many important themes. As an added bonus, it helped her to connect with other organizations. “There was an opportunity for agencies and teams to learn from each other’s programs, stimulating relationships and potential partnerships within our city to best serve youth in Hamilton.” The sessions were originally halfday, but have been extended to full-day so attendees can gain more

knowledge. The fall session booked up within days of being promoted, and Irene has a waiting list for future sessions. “I think that is evidence of how great the need for this education is,” she says. “Mental health is an issue for so many of the young people we work with, and being able to equip workers across our city to support them is really important.” The workshops, called Understanding and Working with Youth who have Mental Health Problems, is free to attend for anyone who works directly with youth in Hamilton. It takes place twice a year at Ron Joyce Children’s Health Centre. For more information, contact: Irene Heffernan at 905-546H 2424 ext: 4929. ■

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Elise Copps is a public relations specialist at Hamilton Health Sciences. www.hospitalnews.com

OCTOBER 2018 HOSPITAL NEWS 25

SAFE MEDICATION

Psychological safety: An essential constituent of continuous quality improvement By Adrian Boucher, Larry Sheng, and Certina Ho iven the complexity of the dispensing of medications, medication incidents are an inevitable part of pharmacy practice. In fact, it is estimated that as many as seven million medication incidents occur in Canadian community pharmacies each year. Quality improvement programs encourage the reporting and analysis of these incidents in an effort to improve learning and prevent recurrence. Unfortunately, reporting and discussing errors among healthcare practitioners is often avoided due to the fear of retribution from both fellow colleagues and management. Overcoming these barriers is necessary to create an environment of psychological safety. Psychological safety refers to the phenomenon where members of a team are comfortable taking interpersonal risks, such as reporting and discussing errors, without fear of negative consequences to self-image, status, or career. In healthcare, where errors form the basis upon which improvements in processes are established, psychological safety sets the foundation in allowing organizations and individual practitioners to learn from errors. The effects of psychological safety can be expressed across three different levels: individual, group, and organizational (see Table 1).

CREATING AN ENVIRONMENT OF PSYCHOLOGICAL SAFETY Development of psychological safety within the workplace promotes sharing of errors via upwards communication. This encourages staff to express concerns and share incidents not only among their peers, but also with executive staff members, resulting in potential for implementation of organization-wide changes and improvements. To develop a work culture that embraces psychological safety, factors

Level

Description

Individual

A working environment where an individual feels psychologically safe elicits confidence, and therefore drives creativity, proactivity, and eagerness to share information with others. Employees are more likely to proactively engage in sharing information with their peers and create opportunity for generative discussion of improvement.

Group

Psychological safety at a group level is encompassed by team learning and continuing innovation developed through task conflict and group collaboration. The resulting supportive networks allow members to learn from shortcomings and incidents, and encourage innovative changes in existing processes to optimize outcomes in the future.

Organizational

Psychological safety at the organizational level involves building relationships between employer and employee, and the development of support networks within the organization. Management practices that promote a sense of psychological safety within the organization facilitate knowledge exchange between peers and create an environment where individuals feel safe taking interpersonal risks.

Table 1. Effects of Psychological Safety at the Individual, Group, and Organizational Levels that influence employeesâ&#x20AC;&#x2122; perception of the work environment must first be addressed. This includes improvement in key areas of interpersonal relationships, management behaviours, and organizational practices. Cumulatively, these factors enhance psychological safety and ensure that employees consistently feel comfortable with sharing any incidents that they encounter.

Management behaviours Supportive and clarifying management processes are the most effective management styles in promoting psychological safety in the workplace. Management characteristics such as inclusiveness, support, trustworthiness, openness, and behavioural integrity strongly influence employee perceptions of psychological safety, which

PSYCHOLOGICAL SAFETY REFERS TO THE PHENOMENON WHERE MEMBERS OF A TEAM ARE COMFORTABLE TAKING INTERPERSONAL RISKS, SUCH AS REPORTING AND DISCUSSING ERRORS, WITHOUT FEAR OF NEGATIVE CONSEQUENCES TO SELF-IMAGE, STATUS, OR CAREER. Interpersonal relationships Interpersonal relationships, and the social support and resources inherent within, promote psychological safety and contribute to team learning, performance, and innovation. Characteristics such as shared team rewards, formal team structures, and engagement in cross disciplinary work improve the strength of social networks and enhance psychological safety.

in turn, fosters beneficial outcomes such as team learning behavior, team performance, engagement in quality improvement work, and a reduction in errors. Organizational practices Supportive organizational practices are positively related to employee work outcomes such as organizational commitment and job performance as they

heighten perceptions of psychological safety. Providing a supportive environment through access to mentoring and implementation of diversity practices promotes open discussion and willingness of staff to express concerns.

PSYCHOLOGICAL SAFETY AND CONTINUOUS QUALITY IMPROVEMENT (CQI) Creating a psychologically safe environment in healthcare settings will be necessary for the success of any continuous quality improvement (CQI) initiatives. The incident reports collected not only help individual departments develop quality improvement initiatives, but also allow aggregate analysis for shared learning within the organization. Without psychological safety, healthcare practitioners will be less likely to report incidents, suggest new ideas, or seek assistance. Creating a positive team dynamic and ensuring management and regulatory support are essential to establishing a safe environment at the individual, group, and organizational levels. By working towards psychological safety, organizations and individual practitioners can better learn from incidents and H improve patient/medication safety. â&#x2013;

Adrian Boucher is a Medication Safety Analyst at the Institute for Safe Medication Practices Canada (ISMP Canada); Larry Sheng is a PharmD Student at the School of Pharmacy, University of Waterloo; and Certina Ho is a Project Lead at ISMP Canada. 26 HOSPITAL NEWS OCTOBER 2018

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Rapid Access Addictions Medicine Clinic Continued from page23 We manage the acute emergency well but the underlying substance issues remain,” she says. “What we do at the RAAM Clinic is start a path towards a much more holistic and effective long-term treatment that can help people stay out of the emergency department.” In the clinic, Dr. Lazier assesses the addiction problem and makes recommendations on medical treatment options. “For alcohol-use disorders there are a number of medications we can use to help patients with cravings and to cut down or eliminate use. With opioids, substitution therapy with suboxone is very successful,” she says. The RAAM Clinic also serves as a resource for family physicians in the community. Physicians can refer their patients here for access to addictions services. Clients of the RAAM Clinic will see an addictions counselor during their visit. Jason Hunter is one of the two counselors. He also works at MGH’s Withdrawal Management Centre. “I’m there to help clients navigate the options available to them and figure out what their goals are,” he says. “We go over their substance-use history, what the client’s current needs are and what goals they may have for themselves.” Working with the goals of the client rather than setting goals for them is part of the RAAM Clinic philosophy. Jason has been working as an addictions counselor for 10 years at MGH’s Withdrawal Management Centre. He started there as a student during a placement. “A great thing about the RAAM Clinic is it provides people with really easy access to information about where they can go for help with addictions,” says Jason. “We can start planting the seeds of treatment options like referring them to the various services of the Withdrawal Management Centre. The RAAM Clinic has seen a number of clients so far and the support they have received has helped many begin to achieve their goals whether it’s abstinence, developing a plan of www.hospitalnews.com

Jason Hunter, RAAM Clinic addictions counselor, believes the clinic is a great first step for those seeking help with addictions. Photo credit: Ellen Samek care, education around anti-craving medications or reducing substance use and harm reduction. “The great thing for me in working in both places is seeing how fluid the transitions are. Clients move back and forth between the two services,” says Jason. “It’s really amazing to see how the two sites can work together to help a client start achieving their goals.” A hope of all of the RAAM Clinic’s staff is to continue to form relationships with other areas of the hospital and the community to help guide clients towards the resources they need. Mental Health Services at Michael Garron Hospital works in partnership with clients and community members to provide a range of care options both on the main hospital campus and in other affiliated sites in the East Toronto community. An interdisciplinary team of physicians, psychiatrists, nurses, occupational therapists, psychologists, psychometrists, social workers, mental health workers, addiction workers and case managers work in partnership with clients to achieve their recovery goals. Off-site areas of care include the Withdrawal Management Centre which maintains a residential program and a day-program. MGH’s Aboriginal Healing Program, led by Elder

Little Brown Bear, combines western and traditional methods of healing to support community members. The

RAAM Clinic is the latest addition to a broad range of services offered by the H hospital. ■

CNA introduces accreditation services With 110 years’ experience in providing credible continuing professional development (CPD) programs to nurses, the Canadian Nurses Association (CNA) is excited to now also offer accreditation services. This endeavour is part of CNA’s new direction to grow its programs, services and networks. Its aim is to support nurses so they can continue to make a real impact on the lives of Canadians. The CNA Accreditation Program helps nurses identify top-quality group-learning and self-assessment opportunities. It also gives external and partner organizations the opportunity to earn national recognition through CNA for their CPD programs, courses, conferences and activities. Eligible applications to the CNA Accreditation Program are carefully reviewed to ensure their learning and development objectives meet CNA’s accreditation standards. Applications that satisfy all the requirements will be assigned credit values based on the activity’s length, complexity and thoroughness. For a CPD activity to be eligible for accreditation, a nursing organization must have played a lead role in its development. To date, CNA has accredited e-learning modules on medical assistance in dying, suicide prevention and the Code of Ethics for Registered Nurses.

For information about the application process and fees, please contact accreditation@cna-aiic.ca

OCTOBER 2018 HOSPITAL NEWS 27

ETHICS

Ethics and the stigma of mental illness and addiction By Daniel Buchman tigma is socially discrediting. It is a complex social and psychological process that is enacted through intersecting individual (e.g., self-stigma), interpersonal (e.g., relationships) and structural (e.g., policies, socio-cultural attitudes, and laws) levels. Sociologists Bruce Link and Jo Phelan state the stigma process involves interrelated elements of separation (i.e., a powerful in-group separates a less-powerful out-group into moral categories of “us and them”), discrimination, status loss, labeling, and stereotyping. Erving Goffman described stigma as a “spoiled identity”, which can remain associated with the person throughout their lives. Some populations tend to be more stigmatized than others, and these groups tend to get sicker, sick more often, and die earlier. Eradicating stigma is of ethical importance. It is well established that mental illness and addiction are highly stigmatized. People living with mental illnesses are often assumed lazy, unpredictable, and violent, despite research demonstrating otherwise. Addictions are often stigmatized because people in Western societies tend to see substance use in tension with deeply held cultural values of autonomy and self-control – so, people who use substances are likely to be held responsible, blamed, and punished for the consequences of their substance-using behaviours. The use of illegal substances, such as heroin, is more stigmatized than legal substances, such as alcohol. Compare mental illness and addiction with cancer, where people

SOME SCIENTISTS, CLINICIANS, POLICYMAKERS, AND CONSUMER GROUPS ARE ADVOCATING FOR MENTAL ILLNESS AND ADDICTION TO BE CONSIDERED BRAIN DISEASES AS ONE WAY TO REDUCE STIGMA. are often not blamed and penalized for developing the disease. Stigma has also led to persistent underfunding of addiction and mental illness research and treatment services. A wealth of research demonstrates the potential harms of mental illness and addiction stigma, including shame, chronic stress, and social isolation. This can translate into barriers in accessing healthcare, housing, and disclosing symptoms to others. Stigma – and the criminalization of substance use – may cause people to use substances in unsafe ways and discourage people from calling emergency services out of fear of arrest. Many healthcare professionals hold stigmatizing attitudes toward people living with mental illness and addictions, even though most professionals are well intentioned and want to benefit their patients. People living with mental illness and addiction often report that they feel disrespected by healthcare professionals, experience a lower quality of care, and perceive that they are not taken seriously. Some scientists, clinicians, policymakers, and consumer groups are advocating for mental illness and addiction to be considered brain diseases as one way to reduce stigma. These

groups highlight findings from neuroscience research that suggest a neurobiological basis for these conditions. Advocates argue that a brain disease framing has the potential to reduce stigma and blame because a neurobiological disease is not an individual’s fault. However, some researchers caution that a brain disease framing may inadvertently intensify stigma. These researchers worry that people living with a mental illness or addiction may be considered neurobiologically flawed – a negative marker of deviance attached to the organ most closely linked with personal identity (i.e., the brain). There is a growing body of research on biological explanations of mental illness and addiction that demonstrates this counterintuitive finding. So, how can we reduce stigma? First, we can alter our language. For example, the Canadian Centre on Substance Abuse changed its name to the Canadian Centre on Substance Use and Addiction. The organization stated that avoiding judgmental words (e.g., abuse) could help to reframe discussions about substance use away from morality and criminality toward discussions about health. Additional recommendations include using language that reflects the health nature

of these issues, language that promotes recovery, and avoiding slang. We can also use people-first language. For example, we can say ‘a person living with a diagnosis of schizophrenia’ vs. ‘a schizophrenic’; ‘a person who uses drugs’ vs. ‘an addict’. People are not defined by their diagnosis or condition. Second, there is some evidence that contact-based educational approaches between people living with mental illness or substance use disorders and more powerful groups (e.g. healthcare professionals) might help reduce stigma by increasing knowledge about these conditions. While the available evidence is promising, more research is needed. We have much to learn from people with lived and living experience of mental illness and addiction. Reducing stigma at the interpersonal level may only be minimally beneficial. We need to confront stigma in the social structures that reinforce and worsen the stigma of mental illness and addiction, especially for populations who are the least well-off. As a society, we have made great strides in addressing the stigma associated with mental illness and addiction, and there are many anti-stigma efforts underway, but more work needs to be done. With one in five people experiencing a mental illness or an addiction in their lifetime, these issues are common. We don’t talk about it as much as we ought to. If we can eradicate the stigma of mental illness and addiction, it may also have the corresponding H benefit of improving health for all. ■

Daniel Buchman is a Bioethicist at the University Health Network, a Clinician Investigator in the Krembil Brain Institute, an Assistant Professor in the Dalla Lana School of Public Health, and a Member of the University of Toronto Joint Centre for Bioethics. 28 HOSPITAL NEWS OCTOBER 2018

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NEWS

Alarming statistics on the mental, emotional and physical health of Canadian children By Amy Metcalfe

agers. Alarmingly, suicide rates for First Nations youth are five to seven times higher, and suicide rates for Inuit youth are 11 times higher, than for non-Aboriginal youth in Canada. Suicide is just the tip of the iceberg, hospitalizations for self-harm have increased 90 per cent between 2009 and 2014, and 14 per cent of children and youth have reported having had suicidal thoughts at some point in time. Individuals who contemplate or commit suicide often struggle with mental health issues, and up to one in five children may develop a mental health disorder, but sadly only 20 per cent of them are able to access appropriate treatment for mental health problems. Between 2007/08 and 2016/17 there has been a 66 per cent increase in emergency department visits and a 55 per cent increase in hospitalizations for mental health issues. Forty-six per cent of in-hospital days for children and youth in 2013-2014 were attributed to treatment of mental health concerns. Mental health concerns are increasingly being recognized in younger children. Children aged 10-14 and 15-17 had the largest increases in emergency department visits and hospitalization for mental health issues. Continued on page 31

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re our kids alright? A recent report from the O’Brien Institute for Public Health at the University of Calgary and Children First Canada suggests that Canadian kids might not be doing as well as we think they are. Canada consistently ranks poorly compared to other developed countries when comparing child health statistics. Children First Canada has recently called for the implementation of a Canadian Children’s Charter and the establishment of an independent national commission for children and youth to advocate for children’s rights within the federal government. Similar Children’s Charters have been established in multiple countries internationally to establish national goals for child health and well-being, engage key stakeholders, and develop an action plan to ensure each child is able to reach his or her full potential. Most comparative statistics of child health status focus on physical health outcomes, yet injury and suicide are the two leading causes of death amongst Canadian children and youth. Canada has one of the highest teenage suicide rates internationally, with an estimated teenage suicide rate of >10 suicides per 100,000 teen-

OCTOBER 2018 HOSPITAL NEWS 29

COVER

AI on the frontlines of suicide prevention: Can we harness social media to help save lives? By Catherine Lewis

hat if we could predict who was at high risk for suicide, long before they were actually in physical

danger? If it sounds like the premise of a scifi novel, you’re not far off – but then again, neither is the technology. In fact, one mental health researcher has already built an algorithm using artificial intelligence that can identify Twitter users at high risk of suicide – the only big question that remains now, he says, is how to best use this technology to help save lives. “This tool takes tweets, and it turns what people say into a number. It asks, ‘How lonely is this tweet? What’s the hopelessness score? What’s the risk score?” says Dr. Zachary Kaminsky, DIFD Mach-Gaensslen Chair in Suicide Prevention Research at The Royal’s Institute of Mental Health Research, affiliated with the University of Ottawa. According to Dr. Kaminsky, the tool can comb through years’ worth of tweets in minutes to pinpoint individuals at risk weeks – even months – before they tweet anything that would raise a red flag to a human reader. In fact, he says, the person writing the tweets might not even be aware that their pattern of speech may indicate risk.

That is because the algorithm doesn’t just use word recognition, and it doesn’t just recognize suicidal ideas – it identifies the actual psychological concepts related to suicide, and scores and matches them alongside all available public data linked to a Twitter user. “This isn’t identifying people saying ‘I’m going to kill myself.’ It’s identifying a risk pattern for people who are moving towards that point,” says Dr. Kaminsky. During a pilot study, Dr. Kaminsky’s algorithm was able to identify suicide risk with an 89 per cent accuracy rate. This high rate of accuracy is especially fascinating, he says, because we can’t fully understand how the algorithm is actually predicting risk. That is because it’s all done through machine learning – part of artificial intelligence – so while we know what information is fed through the algorithm, and what risk score comes out, we don’t actually know what patterns exist within the provided information that are necessary for the machine to get the right answer. “Someone who’s lost someone to suicide shouldn’t think, ‘If only I’d just gone in and read their Twitter I would have seen their risk.’ That is not how this works,” says Kaminsky. “We’ve trained a computer to see things humans can’t see.”

Dr. Zachary Kaminsky, DIFD-Mach Gaensslen Chair in Suicide Prevention Research at The Royal’s Institute of Mental Health Research, affiliated with the University of Ottawa. 30 HOSPITAL NEWS OCTOBER 2018

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COVER

Alarming statistics Continued from page 29

Now with the evidence to show that this predictive tool actually works, Dr. Kaminsky’s next steps are crucial. He sees the potential of the algorithm as a decision-making aid – something that can provide more information or context that could lead to the possibility of early intervention and suicide prevention; particularly amongst Canadians between the ages of 15 and 34, for whom suicide is the second leading cause of death. Because people in this age group are heavy social media users, and Twitter data is completely public, Dr. Kaminsky says it was the obvious social media platform to focus on when building his algorithm.

thing that people can actually use on the frontlines of suicide prevention. The question is, in whose hands should something like this go, and how should they use it?” Initial discussions with the community produced a few ideas. A therapist could use this tool to get a more comprehensive picture of how their patient is doing. It could be used to triage limited resources to those at highest risk. It could be leveraged by social media platforms to push regional suicide prevention information directly to the user. In any case, Dr. Kaminsky believes the eventual tool in any form would be best limited to gatekeepers – people

DURING A PILOT STUDY, DR. KAMINSKY’S ALGORITHM WAS ABLE TO IDENTIFY SUICIDE RISK WITH AN 89 PER CENT ACCURACY RATE.

The question is, who would be getting this information – and how? Would it be the users themselves? Health care providers? Parents concerned about their children? More nefariously, what if it’s a bully? An employer seeking to vet hires? An insurance company seeking to deny coverage? At a World Suicide Prevention Day event at The Royal on Sept. 10, Dr. Kaminsky presented his work for the first time to an auditorium full of people involved in suicide prevention in Ottawa to try to get answers to some of these questions. “We have this tool – I want to hear what you think we can do with it,” Kaminsky said. “I want to create some-

highly experienced in handling private information. As development moves forward, Dr. Kaminsky will be working closely with the community and those who could effectively use this tool on the ground to ensure that it leads to prevention; not harm. “If these tools work as well as we think they’re working, they’re going to help save lives,” he says. The tool needs larger studies and validation in the future, and a determination of the best way to use it, but so far, Dr. Kaminsky says it looks very promising. It’s also something that could be scaled to other social media platforms, and expanded to include the H use of image recognition. ■

Catherine Lewis is a communications advisor at The Royal. www.hospitalnews.com

APPROXIMATELY SEVEN PER CENT OF PUBLIC SPENDING ON HEALTH IN CANADA IS DIRECTED TO MENTAL HEALTH, COMPARED TO UP TO 18 PER CENT IN OTHER DEVELOPED COUNTRIES. While early identification and treatment of mental health concerns is important, the rising incidence of mental health concerns in a younger population has larger implications at a population level as data from the National Longitudinal Survey of Children and Youth in Canada shows that emotional difficulties between the ages of 10-14 years is strongly associated with depression in later teenage years and early adulthood. A multi-faceted approach to treatment of mental health disorders in youth is recommended that may include psychosocial therapy and prescription medication use, and utilization of both psychosocial therapy and psychotropic medication in youth have both increased in recent years. However, many children and youth face barriers to accessing mental health care in a timely fashion. Difficulties accessing mental health services is at least partially attributable to public health insurance in Canada which primarily covers services provided by physicians or in hospitals. This means that approximately seven per cent of public spending on health in Canada is directed to mental health, compared to up to 18 per cent in other developed countries. Lack of access to mental health services has been identified as a priority area for investment for the federal government, with $5 billion being transferred to provincial and territorial governments over a 10 year period address this gap.

While this $500 million annual investment marks an important first step in improving access to mental health care, there is presently an estimated annual $3.1 billion gap in mental health funding that this investment alone will not be able to address. How these investments will be operationalized in each province and territory still remains to be seen. Access to care is only one element that needs to be considered, lack of service integration and coordination of care is frequently reported as a barrier by families, and the transition between pediatric to adult services has been identified as a particularly sensitive time point. Children and youth have many unique health care needs that may not be adequately addressed by the adult system. The Canadian Institutes of Health Research has recently issued a targeted call for research on best practices associated with transitions in care. Most kids in Canada grow up healthy and safe. However, these data show us that there’s still considerable room for improvement. Poor mental health outcomes and lack of access to treatment are important areas for intervention. Canadian children have identified mental health as one of their top concerns, and recent federal investments in mental health may improve access; however, consistent advocacy on behalf of Canadian children and youth is essential to ensure that they have every opportunity to reach their full H potential. ■

Amy Metcalfe, PhD is Assistant Professor, Departments of Obstetrics & Gynecology, Medicine, and Community Health Sciences University of Calgary Foothills Medical Centre. OCTOBER 2018 HOSPITAL NEWS 31

NEWS

Photo courtesy of Aisha Dar, rTMS Clinic

Dr. Downar demonstrates the rTMS machine on a staff member. The procedure helps treat hard-to-treat depression and some other mental illnesses too.

Tackling the barriers of accessibility in

mental health treatment By Jasmine Sikand

r. Jonathan Downar, neuroscientist and psychiatrist at Toronto Western, spent four years completing a PhD in brain imaging. But when it came time for him to practice psychiatry he was surprised to realize he could be a good psychiatrist without applying all of the anatomical knowledge he had obtained. “’Where’ is pretty irrelevant for most of psychiatry, because I can’t make medications just go to the left frontal lobe, or therapy just to the right frontal lobe,” he says. While trying to figure out how to make his knowledge of brain anatomy useful in the clinic, it clicked to him.

32 HOSPITAL NEWS OCTOBER 2018

“I realized that really what I had to do is focus on treatments that were anatomically specific in their effects because then, ‘where’ matters,” Dr. Downar says. But when exploring options for depression treatment, people tend to focus on two things: therapy and medication. What often goes unacknowledged is the third option, rapid transcranial magnetic stimulation (rTMS). rTMS uses magnetic pulses to stimulate the brain in an attempt to strengthen weak connections or weaken connections that are too strong. Dr. Downar says one of the biggest barriers in understanding rTMS as an option for depression treatment is that most

people haven’t even heard of it, despite the fact that it has been approved by Health Canada since 2002. The second barrier is accessibility, including both cost-efficiency and transportation to clinics. “One of the biggest issues with rTMS is that you still have to come into the clinics to get the treatment.” While the quit rate for patients receiving rTMS treatment is only around five per cent, versus 25 per cent for those on medication, the reason for their quitting is often because of the commute to the clinic. A major goal of the rTMS clinic, a part of the Centre for Mental Health at Toronto Western Hospital, is to

find ways to make the treatment more accessible to patients seeking an alternative to medication and therapy. Dr. Downar says the research dedicated to this treatment is crucial because fully two per cent of Canada’s population (around 700,000 people) have treatment-resistant depression, meaning they won’t be successfully treated by medication or therapy. For them, rTMS is a new glimmer of hope that their hard-to-treat conditions can improve. Since science and brain imaging allows doctors to see which brain circuits are either too strong or too weak, they are able to target the problem areas – the ones causing depression. www.hospitalnews.com

NEWS

RTMS USES MAGNETIC PULSES TO STIMULATE THE BRAIN IN AN ATTEMPT TO STRENGTHEN WEAK CONNECTIONS OR WEAKEN CONNECTIONS THAT ARE TOO STRONG. After roughly 20-30 sessions of stimulation, depending on your condition, the depression will gradually improve. In terms of effectiveness, Dr. Downar says about one third of people get a full remission, but that there’s another one third of people who he thinks can come close to remission by treating multiple brain areas. For the last one third the treatment seems to be ineffective. The success rate and number of people this treatment has proven to help keeps Dr. Downar motivated and inspired to find a way for it to be accessible to anyone who needs it. rTMS has been around for over 20 years, but has been quite slow to take off because it has always been expensive, with little to no public funding in Canada, making it difficult for those needing the treatment to get it. In a collaborative study with UHN, University of British Columbia and the Centre for Addiction and Mental Health from April 2018, Dr. Downar and his colleagues were able to come up with an rTMS treatment that would take only about three minutes per session, yet was just as effective as the standard treatment sessions that typically take 37.5 minutes. The treatment was recently approved by the FDA in August, 2018. Using a shorter treatment not only brought waitlists down to a maintainable level, but has also decreased the cost from about $250 to $50 per treatment session, Dr. Downar says. This is a significant decrease, but still poses a problem for many patients where funding is not available. Dr. Downar’s overall hope for UHN’s Centre for Mental Health is to pioneer an approach to mental health care that is more readily available, integrated and universal, bridging the gaps in accessibility often seen in this area of healthcare. While Dr. Downar focuses his efforts on trying to do this effectively

for rTMS, there is still a road ahead to achieving this model. “When you go to the cancer clinic, no one tells you that you have to get in three different five month- long lineups for your radiation, your chemo and your surgery,” he says. “Ideally, there’s one front desk and they just take you in and they try to put together a comprehensive treatment plan. We need that same approach here in mental health. And we’re going to try to get there.” For Dr. Downar, the next step in attaining this standard of care is continuing his research in making rTMS treatment even less expensive and more accessible. The goal is to develop a type of rTMS that is so simple and safe that patients can perform the treatment themselves, in the comfort of their own home. “The next big thing I think is going to be to try and demonstrate that there is a way that rTMS can be done as safely and effectively at home as it can be done in the clinic,” he says. “This includes showing how rTMS has better success, fewer-side effects and fewer safety issues than medications, and that everything we do in this room could also be done just as easily by the patient in their bedroom at home, with the right safety measures in place, so long as we can make the treatments simple and user-friendly.” Downar points to the fact that patients have already been taught how to perform some medical procedures at home, such as injecting their own insulin or doing their own wound care. “If we can show that at-home rTMS is less risky than either of those procedures, and less risky than sending a depressed person home with a bottle of medications on which they could overdose, then we actually have a good argument for homebased rTMS treatment. And with that being demonstrated, we’re one H step closer to access for everyone.” ■

Jasmine Sikand, is a Communications Officer at UHN’s Centre for Mental Health. www.hospitalnews.com

OCTOBER 2018 HOSPITAL NEWS 33

FROM THE CEO’S DESK

Bridging the gap from discovery to patient care By Dr. David Hill edicated health researchers across the country are working every day to make discoveries that improve patient outcomes and support a higher quality of life. Our research hospitals have a mandate to develop and test new treatments, technologies and procedures that address our most pressing health challenges. There is a cycle of health innovation that is supposed to happen – scientific discoveries are made, they transition to clinical trials and then are adopted as an improved standard of care. This is followed by evaluations of the new method and moving along to the next cycle of refinements and improvements. But the reality in Canada is that gaps, in some cases chasms, disrupt the creation and adoption of evidence-based health innovations. This starts with discovery. The research funding climate in Canada continues to be extremely difficult. Despite the Federal Government outlining substantial new investments in discovery research in Budget 2018 much of that money will not be available to researchers until 2020 and beyond, and the Canadian Institutes of Health Research (CIHR) continues to be limited by a low funding rate of around 14 per cent. Funding for large, definitive clinical trials is especially difficult to support with public funds. Too many good ideas are left unfunded, and in that environment researchers can feel it’s wiser to propose incremental and ‘safe’ science that avoids controversy and the risk of losing support for experienced research teams built up over many years. Yet researchers are persistent and manage to secure funding from a range of smaller agencies. Unfortunately, many of these do not fund the indirect costs of research necessary to cover administration, infrastructure, equipment maintenance and upgrades, and the investigator’s salaries. Indirect costs are estimated to be approximately 40 per cent on top of direct study costs. In research hospitals these costs

CURRENTLY, IN MOST PROVINCES, THERE IS NO FUNDING MECHANISM TO TRANSLATE HEALTH INNOVATION TO THE ‘REAL WORLD’ SETTING OF OUR FRONT-LINE CARE.

Dr. David Hill generally fall on the institutions to find funding outside of the provincial government budget that covers the costs of hospital care. This is a negative spiral whereby the more successful a hospital becomes in attracting research funds, the bigger the gap in finding the resources to support that research. When innovative solutions to health care problems are delivered, backed by solid evidence, adoption into our hospital-based care is often far from rapid. Currently, in most provinces, there is no funding mechanism to translate health innovation to the ‘real world’ setting of our frontline care. Yet, such a mechanism is crucial to the translation of science. Clinical trials are carefully designed with strict protocols and criteria for a highly specific population of patients. Innovations that work in a clinical trial do not always work in the real world where patient populations and settings are much more complex. Following a clinical trial, innovation needs to be tested at the point of care. Without funding to do this, research

innovation hits a roadblock. Scientists are left waiting and hoping that one day their provincial government might look to incorporating their innovations into the health system funding schedule. Meanwhile, their work may be used to inform health care improvements in other nations. An example can be found in medical imaging research. Canadian scientists, including those at Lawson Health Research Institute, are leaders in the development of positron emission tomography (PET) biomarkers to improve diagnosis and understanding of disease using PET scans. PET biomarkers are successfully created and then validated in clinical trials across our nation, but there is little funding to translate them back in a timely fashion to patient care in our hospitals. While countries like the US and Europe readily adopt these innovations, Canada lags behind. This gap was addressed in a report to the Federal government by the Advisory Panel on Healthcare Innovation entitled “Unleashing Innovation:

Excellent Healthcare for Canada” and published in 2015. The panel recommended the formation of a Healthcare Innovation Agency of Canada open to hospitals and other care providers in order to evaluate health innovations in the real-world setting of our health system. Scientists would apply by putting forward evidence from their research, including that collected from clinical trials. They would then design a new translational study to test their innovation at the point of care, with the goal of building evidence for presentation to provincial government. Will everything tested at the point of care succeed? No; some things will fail in the real world. This is why such a fund is so important. It will show whether or not an innovation truly benefits patients and if it’s ready for wider adoption. If successful, the evidence will highlight the right time to bring innovations into the mainstream standard of care. By bridging this gap in the system, we can improve patient care and ensure a timely return on the H investment in science. ■

Dr. David Hill is Scientific Director at Lawson Health Research Institute, the research institute of London Health Sciences Centre and St. Joseph’s Health Care London 34 HOSPITAL NEWS OCTOBER 2018

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EVIDENCE MATTERS

The potential of e-Health to improve access to mental health treatment By Eftyhia Helis and Barbara Greenwood Dufour ecent reports suggest that, in Canada, a long-term and systematic approach over the past few years to increase mental health awareness has led to a reduction of mental health stigma, with more and more people being comfortable discussing mental health. However, although mental health is now recognized and discussed more broadly, access to mental health services remains a challenge for many. In an era where technology has become an integral part of our daily lives, e-therapy options could play an important role in creating additional access points for mental health care, thus reducing wait times and facilitating timely access to effective treatment. These options may be also preferred by some patients over faceto-face treatments due to a variety of reasons including, for those living in rural or remote areas, limited access to treatment centres close to home.

WHAT IS CONSIDERED AN E-THERAPY? e-therapy is when mental health treatments are offered remotely via information technology platforms such as the internet or mobile phones (e.g., using apps or via SMS). While some of these treatment options are already available in Canada, health care decision-makers, including patients, want to make sure that they are effective before adopting and implementing them. CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – has completed a number of evidence reviews to assess the clinical effectiveness of e-therapy for a range of mental health conditions including depression, anxiety, post-traumatic stress disorder (PTSD), and substance use and addictions. Below is a summary of relevant findings.

E-THERAPY INTERVENTIONS FOR THE TREATMENT OF PATIENTS WITH DEPRESSION Cognitive behavioural therapy (CBT) is the most evidence-based psychotherapy used to treat depression. In traditional CBT, the patient works face-to-face with a therapist to identify, challenge, and evaluate the thoughts that maintain the depressive mood. With e-therapy, this treatment is delivered using online written materials or audio/video files or a combination of the two, and can be provided either without assistance (self-help) or with the assistance of therapists by phone, video, or email.

CADTH assessed the effectiveness of therapist-guided e-therapies for PTSD from evidence identified in eight studies, which suggest that e-therapy with therapist support may be a promising option for managing PTSD symptoms when compared with waitlist, treatment as usual, or other active treatment. However, the studies typically had a low number of participants and were of variable quality. And it’s unknown whether patient characteristics such as age, type of trauma experienced, level of computer literacy, and educational level impact the effectiveness of the treatment. We need better quality evidence to confirm if e-therapy is effective for PTSD and for which patients.

E-THERAPY IS WHEN MENTAL HEALTH TREATMENTS ARE OFFERED REMOTELY VIA INFORMATION TECHNOLOGY PLATFORMS SUCH AS THE INTERNET OR MOBILE PHONES (E.G., USING APPS OR VIA SMS). According to a CADTH review, evidence from a small number of studies show that e-therapy with therapist support may lead to a larger reduction of depressive symptoms in adults with depression and major depressive disorder compared with no treatment, wait list, or treatment with antidepressant medications. Therapist-guided e-therapy was also found to be equivalent to standard face-to-face CBT for adults with major depressive disorder.

E-THERAPY INTERVENTIONS FOR THE TREATMENT OF PTSD Psychotherapy is frequently used to treat PTSD, a debilitating condition that generally results from exposure to one or a series of traumatic events.

E-THERAPY INTERVENTIONS FOR THE TREATMENT OF ANXIETY Generalized anxiety disorder – the most common mental disorder seen in primary care – is characterized by constant and excessive worry and anxiety that causes significant distress and impairment. Panic disorder and social anxiety disorder are other common anxieties that can cause significant impairment and impact quality of life. CADTH evaluated the evidence from 10 studies on the effectiveness of therapist-guided e-therapy interventions for generalized anxiety disorder, panic disorder, or social anxiety disorder. Overall, these interventions

were found to be more clinically effective compared with waitlist, care as usual, the provision of information, or psychological placebo for all three disorders; and it appears that these interventions may have similar effects to face-to-face CBT.

E-THERAPY INTERVENTIONS FOR THE TREATMENT OF SUBSTANCE USE DISORDERS AND OTHER ADDICTIONS e-therapy interventions are also used to treat substance use disorders and other addictions. A CADTH review of the evidence found that therapist-guided e-therapy might reduce problematic alcohol consumption or cannabis use compared with no treatment and wait list, but it seems to have only a small effect. Current evidence indicates that therapist-guided e-therapy for several mental health conditions may provide effective alternatives to conventional treatment modalities while improving access to care. However, awareness and implementation of e-therapies is still limited in Canada. While e-therapy technologies are changing at a fast pace, in time, more evidence including evaluation of these programs will become available, which may lead to the increased availability of such treatments in the future. The CADTH evidence reviews mentioned in this article are just a few of several that CADTH has undertaken on the topic of mental health. You can find all of our related evidence at cadth.ca/mentalhealth. You can also follow us on Twitter: @CADTH_ACMTS, or talk to our Liaison Officer in your region: cadth. ca/contact-us/liaison-officers. ■ H

Eftyhia Helis and Barbara Greenwood Dufour are knowledge mobilization officers at CADTH. www.hospitalnews.com

OCTOBER 2018 HOSPITAL NEWS 35

LONG-TERM CARE NEWS

Digestive changes with aging:

Upper

digestive tract By Dale Mayerson and Karen Thompson he digestive system is a complex series of structures that use food to fuel and strengthen the body. It is one continuous tube from the mouth to the anus, and reaches approximately nine metres (30 feet) in length. The goal of the digestive tract is to thoroughly break down the food we eat in order to extract the nutrients that keep us healthy. The digestive system starts with the mouth, where food is chewed. The four different shapes of teeth help to grind, shred and tear food into small pieces in preparation for swallowing. Saliva mixes with food to moisten it and an enzyme in the saliva starts to break down starches. The tongue creates small masses of chewed food and moves them to the back of the throat in preparation for swallowing. The esophagus moves food from the throat to the stomach. There are small seals at each end of the esophagus called sphincters, that open and close in response to movement of food through the system. In the stomach, food particles break down due to the hydrochloric acid and enzymes produced in the stomach lining. The stomach also mechanically churns to help this process along. The acid is especially effective on proteins that need to be completely dismantled into amino acids before they can be absorbed into the blood stream. It takes about six hours for food to move through the stomach, although the timing can be affected by the amount of fat as well as the amount of fibre in the food. The resulting mixture moving out of the stomach is a wet, partially dissolved mass, ready for the next step in the small intestine.

36 HOSPITAL NEWS OCTOBER 2018

Although this is a marvellous process, there are many possible “glitches” in the system, and problems develop more frequently with aging. The following is a list of just some of the disorders and conditions of the upper digestive tract:

PERIODONTAL DISEASE Poor oral health, lack of brushing, flossing and regular dental check ups can cause gum disease, leaving teeth loose and damaged. Gingivitis is inflammation of the gums, caused by bacteria building up in plaque, and the more serious periodontal disease causes the inner layer of the gum and bone to be slowly destroyed. This can lead to extreme pain and poor food intake, ultimately requiring tooth removal and the need for dentures. Teeth in poor condition may be sensitivie to very hot or very cold foods. There is evidence that bacteria in the mouth, resulting from poor oral health, has been associated with heart disease and dementia, and can make diabetes worse.

SALIVA FLOW We produce up to a litre of saliva per day, but saliva may be reduced with aging, making it more difficult to moisten food while chewing and swallowing. Less saliva also makes it more difficult to taste food, possibly affecting the person’s overall food and nutrient intake. Medications can cause side effects such as dry mouth, leading to tooth damage. Dry mouth is medically termed xerostomia.

DENTURE USE Dentures must fit correctly over the gums, to avoid rubbing and irritation that can lead to open sores. Dentures www.hospitalnews.com

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ASSESSING RESIDENTS FOR CHEWING, SWALLOWING, DIGESTIVE PROBLEMS, AND ANY OTHER REASON FOR POOR INTAKE AT MEALS AND SNACKS, IS THE FIRST STEP IN SETTING UP INDIVIDUALIZED INTERVENTIONS. must also be cleaned regularly and frequently, to avoid food particles being trapped in the dentures or between the dentures and the gums. Food particles that are swallowed hours after eating can lead to symptoms of food poisoning.

DYSPHAGIA Swallowing disorders can cause food to land in the trachea – the tube leading to the lungs, instead of going into the esophagus. Even though swallowing can take just a second or two, more than 50 muscles are involved. Dysphagia is often a result of dementia, stroke, Parkinson’s disease and other med-

ical conditions, such as cancer of the throat. Food may need to be pureed to a smooth homogeneous texture, to make it as safe as possible to swallow.

REFLUX Also known as heartburn, this is a problem with the lower sphincter of the esophagus. The highly acidic environment of the stomach can splash up into the esophagus if the sphincter is not tightly closed, causing pain or a burning sensation. This can be an occasional occurrence, but if it is an ongoing problem, it is better known as GERD – gastroesophageal reflux dis-

ease. Advice for reflux includes: eating smaller meals, avoiding caffeine and spicy foods, and sitting up for 30 to 60 minutes after eating. There are many antacids and other medications that help to relieve this problem. Like all systems in the body, the digestive system gradually ages in its functioning, causing changes that can affect eating and nutrient intake. Due to dental problems, many residents in long-term care can no longer chew hard foods or thick, solid pieces of meat. For some frail seniors, even the act of chewing and swallowing can be tiring, so a softer texture increases the opportunity for intake of more nutrients in a meal. Foods that are easier to digest still need to have substantial protein and other nutrients. Some seniors feel a loss of appetite, possibly due to reduction in the taste or smell of foods. This can be made worse with some medications. It is important to assess residents to ensure that they

are able to get everything they need nutritionally from their meals before turning to liquid oral nutritional supplements. In long-term care, this is becoming known as the “food first” philosophy. Poor food and fluid intake can lead to a whole host of problems such as: frailty, unwanted weight loss, skin breakdown, greater risk of falls, and more. Assessing residents for chewing, swallowing, digestive problems, and any other reason for poor intake at meals and snacks, is the first step in setting up individualized interventions. Seniors in long-term care greatly benefit from consistent daily oral care and visits with a dentist and denturist as required. Residents also need a quick resolution to gastrointestinal problems and complaints, with interdisciplinary team involvement – doctor, nurse, dietitian and front line staff all doing their parts to ensure that residents are eating and drinking, and for H best quality of life. ■

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” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians in Canada.

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LONG-TERM CARE NEWS

ALC prevention puts patients first By Michael Oreskovich atients who have completed their treatment, but continue to occupy hospital beds while waiting to transition to an appropriate care setting are designated as alternate level of care (ALC). According to Cancer Care Ontario, 15 per cent of Ontario’s hospital patients are ALC, as an increasing number of people have difficulty getting the post-discharge care they need in the healthcare system. The number of ALC patients are growing as the population matures and as a result, others are prevented from accessing timely hospital care when they need it most. Runnymede Healthcare Centre, a 206-bed rehabilitation and complex continuing care hospital, is addressing this serious issue by strengthening admissions and discharge processes, which cut its ALC inpatient days in half. This astounding result enables patients to access care in settings that best meet their needs, and illustrates the hospital’s patient-first philosophy. When Runnymede’s patients attain their treatment goals but face obstacles to discharge such as accessing LTC or other kinds of community care, they are designated as ALC. “For us, tackling this challenge meant proactively removing barriers to patients’ next care destinations, by putting their needs at the centre of our decision-making processes,” says Runnymede’s Vice President of Strategy, Quality and Clinical Programs, Sharleen Ahmed. “We developed a strategy that ensures patients have a clear path back to the community after their treatment at our hospital is complete.” The results of the strategy speak for themselves – between 2017 and 2018 Runnymede’s ALC rate fell from 10.3 inpatient days (per 100) to 4.7. Key to this strategy was combining Runnymede’s patient flow and social work teams into one new department, called access and flow. According to Ahmed, putting the teams together makes perfect sense. “The work they do is so complementary – our patient flow staff manage admissions, and

Runnymede Healthcare Centre strengthened its admissions and discharge processes, increasing access to healthcare settings that meet patients’ needs our social workers facilitate discharges,” she says. “We also created a new transition coordinator role, which has an overview of patients’ entire care journeys, from before admission right through to their reintegration into the community.” Before patients are admitted to Runnymede, a patient-centred discharge plan is made. In addition to outlining treatment goals, the plan maps out a pathway to the patient’s next level of care. During the discharge planning process, the hospital places a high priority on identifying and resolving risks that could predispose a patient to being designated as ALC during their stay. “If, for example, patients or families haven’t applied for long-term care or arranged for home care, the chances of becoming ALC while staying at our hospital is much higher,” Ahmed says. “We work with them and our referring partners to address issues like these before admission.” During treatment, weekly ALC avoidance rounds are held with Run-

nymede’s interprofessional team, which gives access and flow insight into each patient’s progress with their discharge plan. If a patient shows signs that they are steering away from their plan, access and flow takes the proactive step of launching an early escalation meeting with their family to prevent the patient from becoming ALC. Families’ reasons for being hesitant about staying with their discharge plans vary, but they are usually rooted in fear of the unknown. “After a patient has been in our care, family members sometimes start to worry about bringing them home, or transferring them to a new care setting,” says Ahmed. “Our access and flow department’s role is to listen to their concerns, build their confidence with emotional support, and show them how their discharge plan is not only possible, but is in the patient’s best interests.” In addition to providing moral and emotional support like this, access and

flow provides one-on-one education to family members and helps connect them to the resources they need. For patients who may not be able to return home, the department can facilitate their transition to long-term care; for patients who plan on returning home, access and flow connects families to community supports that will help the patient thrive. For patients and families experiencing financial pressures, the department will highlight available solutions. Ultimately, the goal of Runnymede’s ALC strategy is to ensure patients get the right care in the right place at the right time. “Even though our healthcare system is running above capacity, our ALC strategy shows we can continue to put patients’ needs first and make it possible for them to access the care they need,” says Ahmed. “Our strategy ensures our rehab programs are being used to their highest potential, and that we’re making our care available to those who need it the H most, when they need it.” ■

Michael Oreskovich is a Communications Specialist at Runnymede Healthcare Centre. 38 HOSPITAL NEWS OCTOBER 2018

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First-ever Canadian Charter of Rights for

People with Dementia n September 5th, the Alzheimer Society of Canada launched the first-ever Canadian Charter of Rights for People with Dementia. The landmark Charter is the culmination of over a year’s work by the Society’s Advisory Group of people with dementia, whose members represent different walks of life from across the country. With the number of Canadians with dementia expected to hit nearly one million in less than 15 years, the Advisory Group set out to define a set of seven explicit rights to give a greater voice and authority to those with dementia. The Charter will help people with dementia as well as their families challenge situations where they experience stigma, are treated unfairly, discriminated against, or are denied access to appropriate care.

• to be informed and supported so they can fully participate in decisions affecting their care and life, from the point of diagnosis to palliative and end-of-life care. • to expect that professionals involved in all aspects of their care are trained in dementia and human rights and are accountable to uphold these rights. • to access effective complaint and appeal procedures when their rights are not protected or respected. “People with dementia, no matter the stage of their disease, have the same rights as every other citizen,” says Pauline Tardif, CEO of the Alzheimer Society of Canada. “Yet, we know all too well that Canadians with dementia continue to face cultural, social and economic barriers to claiming these rights, leaving many facing discrimina-

THE CHARTER WILL NOT ONLY HELP COMBAT THE ONGOING STIGMA ASSOCIATED WITH DEMENTIA, BUT ALSO HELP INFORM A RIGHTS-BASED APPROACH TO THE DEVELOPMENT OF SERVICES AND SUPPORTS FOR CANADIANS WITH DEMENTIA. The Charter empowers Canadians with dementia to self-advocate while also ensuring that the people and organizations that support them know and protect their rights. These include the right: • to be free from discrimination of any kind. • to benefit from all of Canada’s civic and legal rights. • to participate in developing and implementing policies that affect their life. • to access support and opportunities to live as independent and engaged citizens in their community.

tion, isolation and treatment that contravenes their basic rights as human beings. We’re asking all Canadians to champion this new Charter.” The Charter will not only help combat the ongoing stigma associated with dementia, but also help inform a rights-based approach to the development of services and supports for Canadians with dementia. In particular, it will serve to guide the federal government as it follows through on its commitment to develop and implement a national dementia strategy for Canada.

British Columbia resident Mario Gregorio, one of the Advisory Group members who contributed to the Charter, says: “As a person living with dementia, it gives me confidence to know that I’m not alone and reassurance that my country, my health and social services and my family, friends and community are there to lend a hand. We, as a nation, need to play a

leadership role to ensure that people with dementia are not marginalized.” Throughout the month of September, the Society featured stories written by some of the Advisory Group members on what the Charter means to them. To read the stories, learn more about the Charter and download a free copy, in English or French, visit H alzheimer.ca/Charter. ■

This story was originally published on OMNI Health Care’s website, The OMNIway. Reprinted with permission. 40 HOSPITAL NEWS OCTOBER 2018

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LONG-TERM CARE NEWS

Want to improve health outcomes of older adults in hospital? Ask a nurse By Megan Mueller ndividuals 65+ years of age often have multiple comorbidities – that is, secondary diseases that are related to a primary disease. For example, older patients with coronary artery disease may also have diabetes or depression. Simply put, these individuals experience complex and acute health issues. In healthcare facilities, such as hospitals, these vulnerable patients require numerous different professionals to communicate well and work seamlessly together to support them and prevent their decline. This process has been the subject of many research endeavors but, to date, one key expert voice is missing: the nurse’s perspective. New research from York University, led by Post-Doctoral Visitor Jef-

frey Butler, under the supervision of Health Professor Mary Fox, and funded by the Ontario Ministry of Health and Long-Term Care and the Ontario Ministry of Research & Innovation, fills this important gap. Through focus groups with nurses, Butler and Fox identified novel approaches in interprofessional (IP) communications to improve the health outcomes of older adults in hospital. “Our research offers new insight into nurses’ assessments of the usefulness of various modes of communication surrounding care for acutely ill or injured older people. Our recommendations may inform the implementation of initiatives to improve IP communication more generally,” says Butler. The findings were published in Health Communication (2018).

AGING POPULATION IS A PRESSING POLICY ISSUE Given the aging population – arguably, one of the most important policy issues of our time – information about high users of hospital services is of great interest and importance. Statistics are compelling: • Canada’s older (65+) population is growing so much so that, by 2036, it is expected to make up 25 per cent of the population – this, compared to 14 per cent in 2010 (Canadian Medical Association). • Last year, Canada spent $242 billion on healthcare, and hospital expenditure comprised a very large share of this (Canadian Institute for Health Information/CIHI). • Older adults are frequent users of healthcare services, with the system spending more on them than on any other segment of the population (CIHI). • Healthcare costs increase with age: At 65 to 69 years of age, the annual per person cost is $6,298. By age 80+, this number jumps to $20,917 (Canadian Medical Association). A more complete understanding of high users of healthcare could lead to both improved health outcomes of this population and a reduction of hospital costs. That’s why Butler and Fox’s research is so relevant.

RESEARCHERS CONDUCTED 13 FOCUS GROUPS WITH 57 NURSES IN ONTARIO

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Given nurses’ key role in caring for older patients in hospital, Butler realized what could be gained through qualitative research with nurses. In his study, 57 nurses, including registered nurses (RNs) and registered practical nurses (RPNs), working in acute-care hospitals in Ontario participated in 13 focus groups.

NURSES SHARED KNOWLEDGE ABOUT BEST WAYS TO COMMUNICATE Via this qualitative research, nurses passed on knowledge from their lived experiences. Two categories emerged: direct and indirect communications.

CATEGORY 1: DIRECT, FACE-TO-FACE COMMUNICATION Study participants favoured face-toface communication with other professionals because it provided context for the patient’s health, on-the-spot elaboration and further explanation or clarification. They emphasized that this was particularly important since older people’s health status can quickly deteriorate. “Care promoting older people’s functioning requires more frequent direct communication than younger patient populations to keep other professionals up to speed regarding older people’s functional states and prevent further decline,” Butler explains.

IMPORTANCE OF HUDDLES AND ROUNDS Nurses in emergency departments underscored the importance of bedside dialogues, hallway huddles and quick chats at the nurses’ station. One RN mentioned the success of five-minute ‘safety huddles’ pertaining to falls prevention. Nurses in medical-surgical units and coronary care units (CCUs) said that they valued IP rounds as great opportunities to share information. (Patient rounds, led by attending physicians, involve several healthcare professionals. Here, all parties coordinate care.) This revealed a weakness in the system: “One recurring criticism was that nurses’ presence at IP rounds has been increasingly de-prioritized or eliminated altogether. Many believed that

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LONG-TERM CARE NEWS

CATEGORY 2: INDIRECT COMMUNICATION

RESEARCH OFFERS COMMUNICATIONS TIPS FOR ADMINISTRATORS AND PRACTITIONERS

The study also looked at indirect communication – for example, computerized, information technology (IT) tools that centralize a patient’s progress and status. This often backfired. “Numerous participants described portable computers that froze and batteries that did not last,” Butler explains.

In summary, this new research makes three key findings: 1. Direct face-to-face communications, huddles in the hallway, etc. are successful ways to communicate, given the vulnerability of this population. 2. Nurses’ attendance in IP rounds and the frequency of the rounds (daily) are key to positive health outcomes. 3. Low-tech modes of communication, such as summary sheets and whiteboards, could improve communications and, in turn, lead to better health outcomes. These findings could help to guide future communications strategies across numerous healthcare contexts – not just hospitals, and not only in the H care of older patients. ■

ANALOG TOOLS SEEN AS USEFUL, COST EFFECTIVE Rounds were seen as good opportunities to share information where nurses’ attendance was essential. this allows crucial information to fall through the cracks,” says Butler. Participants also said that more frequent, daily rounds were the most effective way to communicate. (This

is not always possible or feasible – for example, on weekends.) One RN says: “Daily rounds […] really heighten your ability to care for the patient.”

Rather than advocating IT solutions, the study participants said that simple, low-tech, cost-effective analog tools, such as bedside whiteboards, were very useful for sharing information in a timely fashion. Hand-written ‘summary sheets,’ housed in patients’ files, were cited as beneficial by a few CCU nurses.

Megan Mueller is Manager, Research Communications, Office of the Vice-President Research & Innovation, York University.

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NEWS

Hospital program brings rapid-access addiction medicine to clinics across Ontario By Jen Brailsford n 2017, more than 1,200 opioid-related deaths were reported in Ontario – up from 867 in 2016. As these numbers continue to climb, the need to find sustainable healthcare solutions addressing addiction is greater than ever. In 2015, the Mentoring, Education, and Clinical Tools for Addiction: Primary Care-Hospital Integration (META:PHI) program, housed at Women’s College Hospital (WCH), developed the Rapid-Access Addiction Medicine (RAAM) clinic model. The RAAM model helps patients overcome alcohol, opioid and other drug addictions by providing integrated, barrier-free care, where patients without an appointment can be seen in under three days. “After receiving urgent care following an overdose many patients are released back into the community without being referred to an ongoing treatment program or are faced with an extended wait to enter a program,” explains Dr. Meldon Kahan, medical director of the Substance Use Service at WCH. “These wait times can often be up to eight months, and don’t include a coordinated plan for recovery.” Key to the effectiveness of the RAAM model is that clinics not only see patients rapidly but also create a continuum of care by liaising between emergency departments, addictions specialists, primary care providers and front-line community services, such as withdrawal management centres and shelters. After piloting the model in seven Ontario communities, META:PHI was funded by the Toronto Central Local Health Integration Network to bring RAAM clinics to Toronto-area hospitals. In 2017, WCH opened downtown Toronto’s first addiction clinic to accept all patients – from self-referrals to those referred by family doctors, hospitals, emergency departments and community groups. The

Kate Hardy, META:PHI project manager, Women’s College Hospital, and Dr. Meldon Kahan, medical director of the Substance Use Service at Women’s College Hospital.

KEY TO THE EFFECTIVENESS OF THE RAAM MODEL IS THAT CLINICS NOT ONLY SEE PATIENTS RAPIDLY BUT ALSO CREATE A CONTINUUM OF CARE BY LIAISING BETWEEN EMERGENCY DEPARTMENTS, ADDICTIONS SPECIALISTS, PRIMARY CARE PROVIDERS AND FRONT-LINE COMMUNITY SERVICES, SUCH AS WITHDRAWAL MANAGEMENT CENTRES AND SHELTERS. WCH RAAM clinic has proven to be a success, seeing 256 unique patients in its first 16 months of operation. The clinic is open to both referrals and walk-ins three mornings per week. During their first visit, patients participate in an initial assessment with an

addiction physician to discuss treatment goals and planning, which typically includes both psychotherapy and pharmacotherapy. They may also meet with a nurse, social worker or addiction worker, depending on their needs. The patient is encouraged to visit

the clinic regularly until they and their treatment team are confident that the patient is stabilized, whether with an optimal medication dose or having established a lifestyle that supports their recovery goals. At this point, ongoing treatment is transferred to their primary care provider who can provide a more holistic healthcare plan. The barrier-free model has proven such a success that META:PHI was funded by Adopting Research to Improve Care (ARTIC) to support a secondary spread, helping to bring RAAM clinics to hospitals and healthcare centres across Ontario. Since the pilot, the program has grown from seven participating clinics in 2016 to more than 55 RAAM sites across Ontario today. Continued on page 45

Jen Brailsford is Communications Lead at Women’s College Hospital. 44 HOSPITAL NEWS OCTOBER 2018

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NEWS

Research grant helps to study blood thinner therapy for children at SickKids Continued from page 44 The reason for this rapid expansion? Healthcare providers are noticing that RAAM sites are alleviating demand on the healthcare system and reducing overall costs by engaging patients before there is an emergency. In communities with rapid-access clinics, hospitals are seeing a decline in emergency department visits and a reduction in hospital stays by those that access RAAM services. “Feedback from communities that have adopted the RAAM model has been overwhelmingly positive, and the purpose of META:PHI is to support the continued spread of the model by providing clinicians in diverse care settings with the tools they need to deliver high-quality, evidence-based care to patients with substance use disorders,” explains Kate Hardy, META:PHI project manager, WCH. “We do this by providing opportunities for education, training, mentorship and networking.” The support provided by META:PHI includes an online community of practice for clinicians and administrators, where participants can access addiction-related Q&As and case discussions, an online repository of clinical and educational materials hosted on the program’s website. Additionally, the META:PHI team hosts regular conferences that healthcare teams can attend in-person or remotely. In September 2018, the program hosted approximately 150 physicians, social workers, addiction workers, administrators and policy makers from across Ontario at a two-day conference to share and discuss the latest best practices, elements of high-quality care and case-based learning, amongst other tools. As awareness and support for the program grows, the META:PHI team at WCH is optimistic that the RAAM model will continue to spread and improve care for patients with addiction while building capacity within the proH vincial healthcare system. ■

By Dr. James Douketis Neurology Stroke Fellow at The Hospital for Sick Children (SickKids) in Toronto is looking to the past to reveal critical data to help her refine guidelines for the use of antithrombotic therapy in children with congenital heart disease (CHD) and arterial ischemic stroke (AIS). Dr. Elizabeth Kouzmitcheva was recently awarded the 2018-2019 Thrombosis Canada-CanVECTOR Research Fellowship that provides funding for this much needed study into the use and safety of blood thinners in paediatric patients for secondary stroke prevention. Her work will involve reviewing clinical and radiological data of more than 200 patients with cardioembolic stroke, enrolled in the SickKids Paediatric Stroke Registry since 1995, founded by Dr. Gabrielle deVeber. Paediatric stroke has emerged as a major contributor to brain injury in infancy and childhood. In Canada, one in every 100 children is born with CHD. Anticoagulant (blood thinner) treatment is routinely recommended for children with CHD and cardioembolic stroke due to a high risk of stroke recurrence. However, no evidence-based trials have addressed anticoagulation use in paediatric cardioembolic stroke due in part to safety concerns. Dr. Kouzmitcheva’s research project is expected to provide crucial safety data that will translate into better care for these infants and children. “We are thrilled with the caliber of applicants that we received for this year’s fellowship, as they gave the committee a lot to consider,” says Sudeep Shivakumar, MD, the Thrombosis Canada Fellowship Committee Chair. “In the end, we decided that Dr. Kouzmitcheva’s research project was an opportunity that we didn’t want to miss as it will provide a valuable new piece of evidence in an underserved population.”

Dr. Douketis with Dr. Kouzmitcheva (right) at a recent meeting at SickKids, when Dr. Kouzmitcheva was presented with the research funding. Dr. Kouzmitcheva says that while up to 25 per cent of children with CHD experience stroke, there is no solid safety and efficacy evidence behind the use of blood thinners that are used to treat and prevent blood clots in children with cardioembolic stroke. “Currently, we use many of the same blood thinners in children with CHD as we do in adults, based on data extrapolated from adults and from our own experience,” she says. “But what we really need to inform best practices, are new paediatric studies to be done so that guidelines can be refined, and we actually have evidence of safety in the use of such therapies in this population of children.” While past studies have shown a higher risk of stroke occurrence for CHD patients when blood thinners are not used, Dr. Kouzmitcheva says the studies have limitations in examining the types of anticoagulants used, dosing and efficacy. “It is more about understanding the risks versus the benefits of anticoagulation in these populations. Children with CHD typically have a higher risk of clotting as well as bleeding as they can experience numerous corrective surgeries and procedures and need blood thinners to prevent clots in their heart, body and brain.”

“We know that not every type of CHD is the same and certain types of CHD can predispose a child to cardioembolic stroke or are associated with a higher risk of cardioembolic stroke than others,” adds Dr. Kouzmitcheva. “There’s still an uncertainty in using blood thinners – both with the risk associated with bleeding in the brain and body, and in knowing what types of CHD will benefit the most from this type of therapy. This research hopes to provide evidence in paediatric patients that there is safety in the therapy such children are receiving.” Since its inception in 1993, the Thrombosis Canada – CanVECTOR Fellowship has provided a springboard to launch the careers of aspiring young researchers. Previous recipients of this award have gone on to carry out internationally recognized research in thrombosis and become international leaders in this field. We look forward to following Dr. Kouzmitcheva’s career, learning of her research and how it will benefit children in the prevention of stroke and other thrombotic vascular disease. Dr. Kouzmitcheva agrees. “With the funding of this research, we feel the scientific knowledge that can be gained will hopefully impact children H in Canada and around the world.” ■

Dr. James Douketis is the President of Thrombosis Canada and Director of the Vascular Medicine Program at St. Joseph’s Healthcare, Hamilton. www.hospitalnews.com

OCTOBER 2018 HOSPITAL NEWS 45

NURSING PULSE

Book buzz at Queen’s Park

harkens back to beginning of BPG program By Doris Grinspun hen a cabinet minister asks: “Is the book out yet?” you know that book is important. That’s what happened when I congratulated Jim Wilson on his appointment as our new minister of economic development while at Queen’s Park for the Throne Speech in July. I was there with our president Angela Cooper Brathwaite and RNAO’s acting policy director Sarah Boesveld when he asked for the link to Transforming Nursing Through Knowledge, our recently released book. Wilson was health minister when I began at the Registered Nurses’ Association of Ontario (RNAO) as then executive director in 1996. RNAO was not the powerful organization it is now, but he and I were able to develop a strong working relationship based on respect. During our visit to the legislature this past July, I felt the strengthened presence of RNAO. I have seen our growth over two decades of working with different governments, and I have watched perspectives on nursing change. As a profession, we are now heard like never before. This bodes well for Ontarians and for nursing. On June 7, Ontarians voted in a new government. Since then, the cabinet has taken shape, and we have been working closely with many politicians with whom we had already developed close relationships. They include ministers: Christine Elliott (health), Raymond Cho (seniors and accessibility), Steve Clark (municipal affairs and housing), Vic Fideli (finance), Ernie Hardeman (agriculture, food and rural affairs), Sylvia Jones (tourism, culture and sport), Lisa MacLeod (children, community and social services, and women’s issues), Monte McNaughton (infrastructure), Laurie Scott (labour), Todd Smith (government and con-

Doris Grinspun sumer services, and government house leader), Lisa Thompson (education), Jim Wilson (economic development), John Yakabuski (transportation), and Jeff Yurek (natural resources). Members also have developed relationships with these and many other MPPs in their communities. These relationships will continue to flourish, as will our relationships with Ontario’s NDP, Liberal and Green party MPPs. This is the beauty of RNAO and its policy – and non-partisan – approach to issues. Regardless of the party in power, we continue to be driven by healthy public policy and what’s best for Ontarians, while being fair and respectful in politics. We give praise when praise is due, and raise our voices when necessary.

Following the Throne Speech, reporters asked me how RNAO will work with the new government. The answer was straightforward. For RNAO, the first priority is Ontarians in times of health and illness. Everyone – without exception – is important to RNAO. Second, the health system belongs to Ontarians and needs to serve everyone today and for generations to come. As nurses, we are here to serve the people and the health system, not politicians. And we are very clear about that distinction. That is why our priorities have not changed from those outlined in RNAO’s pre-election policy platform Improving Health for All. We will continue to work with all elected MPPs to build a province we can all take pride in and enjoy.

Getting back to the book, Transforming Nursing Through Knowledge is about RNAO’s best practice guideline (BPG) program. I was so touched by Wilson’s recent query because this program began in 1998 with his PC colleague and esteemed former health minister Elizabeth Witmer. It has continued with premier after premier, each wholeheartedly embracing the program. It is inspiring to see premiers and ministers as proud of the BPG program as any nurse in Ontario and around the world. Writing a book about our groundbreaking BPG program and forceful push towards evidence-based nursing practice was always in the back of my mind. It became a reality – within a year – through strategic planning and hard work with my colleague and co-author, Irmajean Bajnok, former director of the program. The book delves into the development of BPGs, implementation science, and evaluation. I am so proud of the way we have brought theoretical concepts to life through the narratives of our Best Practice Spotlight Organizations (BPSO) (health care and academic organizations selected by RNAO through a request for proposals process to implement and evaluate RNAO’s BPGs). In writing the book, we had the exquisite support of Josephine Mo, my executive assistant, as well as our publisher, Sigma. We reached out to BPSOs at home and abroad to share their experiences and inspire others. BPSOs have one common goal: to arm nurses and other health professionals with the best evidence to inform their everyday practice and optimize patient outcomes. The book shines a light on nursing’s collective success and its impact on a more responsive, effective, efficient health system. I hope you H pick up a copy. ■

Doris Grinspun, RN, MSN, PhD, LLD(HON), DR(HC), O.ONT, is chief executive officer of the Registered Nurses’ Association of Ontario (RNAO). This column was originally published in the July/Aug 2018 issue. RNAO is the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. 46 HOSPITAL NEWS OCTOBER 2018

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What suicide notes teach us about experiences with mental illness By Sean O’Malley an the study of suicide notes help clinicians in their efforts to prevent suicide? That is the premise of a new study by the Centre for Addiction and Mental Health (CAMH) and Sunnybrook Health Sciences Centre, published in the Canadian Journal of Psychiatry. The unique study examined 1,565 cases of suicide, identified through the Office of the Chief Coroner of Ontario, which occurred between 2003 and 2009. In approximately one-third of those cases, a suicide note was referenced, and in 290 cases a copy or transcription was included in the file. Within that group, the study authors focused on a subset of 36 suicide notes that explicitly referenced mental illness and/or mental health care. “By investigating suicide notes, we have an opportunity to improve our understanding of the mind-set of people in the moments prior to their suicide deaths. The hope is that we can use this information to understand patterns of thinking that contribute to suicide. These patterns can be targets of treatment in those at risk,” says senior author Dr. Juveria Zaheer, a Clinician Scientist in CAMH’s Institute for Mental Health Policy Research. Within the notes, the authors found three primary themes that could improve the identification and treatment of those with mental illness who are at risk for suicide.

FEELINGS OF CONTROL AND POWERLESSNESS Many people who died by suicide felt that they had no control of their mental illness and its impact on their lives. Others felt that they maintained control over their lives, but were angry at themselves for being unable to change the trajectory of their illness.

SEEING THEIR SITUATION AS A BATTLE BETWEEN THE ‘REAL SELF’ AND MENTAL ILLNESS

in assessing the risk of suicide is the importance of understanding the different ways their patients interpret their mental illness. By understanding

Several writers framed mental illness as an opponent that must be “fought,” which seemed to use up valuable mental and emotional resources. They perceived the struggle as a “losing battle,” leading to feelings of exhaustion.

Careers

EXPERIENCES OF MENTAL HEALTH TREATMENT THAT LEAD TO HOPELESSNESS AND SELF-BLAME In over half of the suicide notes, the writers referred to previous mental health treatment. While some expressed a sense of hopelessness, feeling that there was nothing that could be done to help them get better, others blamed themselves for not responding positively to treatment. In the context of severe depression and other mental illness, it can be difficult for patients to maintain hope that their condition will improve. The authors stress that mental illness is treatable and that all people who are affected deserve to have timely access to high quality treatment. One of the implications for clinicians

Sean O’Malley works in Media Relations at The Centre for Addiction and Mental Health. www.hospitalnews.com

the inner thoughts of a person prior to dying by suicide, there are obvious clinical implications for this research. “It is very important for clinicians to talk to their patients about their thoughts and beliefs about having a mental illness and going through mental health care,” says lead author Dr. Zainab Furqan, a psychiatry resident at the University of Toronto. The authors say clinicians should make a conscious effort to identify feelings of helplessness or a sense of hopelessness in the context of a depression, creating an opportunity for interventions that H may reduce the likelihood of suicide. ■

“BY INVESTIGATING SUICIDE NOTES, WE HAVE AN OPPORTUNITY TO IMPROVE OUR UNDERSTANDING OF THE MIND-SET OF PEOPLE IN THE MOMENTS PRIOR TO THEIR SUICIDE DEATHS. THE HOPE IS THAT WE CAN USE THIS INFORMATION TO UNDERSTAND PATTERNS OF THINKING THAT CONTRIBUTE TO SUICIDE.”

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