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September 2017 Edition
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Public inquiry will lead to better care By Doris Grinspun t was a tragic day for the nursing profession when news broke last October that former RN Elizabeth Wettlaufer would be charged with the murders of eight elderly Ontarians using a lethal dose of insulin in each case. She was also charged with four counts of attempted murder and two counts of aggravated assault. As details emerged about this serial killer, RNAO and its members were outraged that a colleague could commit such a gross violation of the most sacred principle of our profession – the unwavering commitment to ensure the well-being of patients and their families. RNAO began advocating for a full public inquiry when the former RN pleaded guilty to the murders in early June. As the only nursing organization to issue this call, we spoke to the media, sent letters to political leaders, and circulated two action alerts urging members to voice their outrage. More than a thousand people joined us in demanding answers to what happened, how it happened, and what can be learned from an organizational, regulatory and system perspective to ensure nothing like this ever happens again. On June 26, the same day Elizabeth Wettlaufer was sentenced to life in prison with no chance of parole for 25 years, the government announced it would launch a public inquiry. The details of that inquiry were revealed on Aug. 1, and nurses across the province are applauding the government for having the courage to put this tragedy under the microscope. We are especially pleased that Premier Kathleen Wynne, Attorney General Yasir Naqvi and Health Minister Eric Hoskins have heeded our calls for an inquiry with a broad mandate. We are now urging Justice Eileen Gillese, a sitting judge with the Ontario Court of Appeal since 2002, to make full use of this broad mandate as the inquiry’s commissioner. She must look at anything and everything that might have contributed to this horrific tragedy.
Funding models in long-term care penalize nursing homes for improving patient outcomes RNAO is also urging Justice Gillese to look beyond this particular case and make recommendations to address the failings of our long-term care system, including examining legislation and regulations, funding models and staffing, and any other aspects required to create a safer environment for seniors living in nursing homes. RNAO has received numerous calls from nurses who have revealed to us that things are just not right in their nursing homes. They have told us patients are not turned as often as nec-
essary, and some sleep all night in the same soiled diapers. We have thanked each caller for their courage to disclose the truth. And we are urging others to continue to share their concerns with us. We know the vast majority of nurses – RNs, RPNs and NPs – go to work wanting to do good and wanting to deliver safe, quality care. The staffing circumstances, however, are deficient, if not deplorable. Older persons deserve the best evidence-based care we can provide. Their vulnerability is greater than ever
as they arrive in long-term care older and frailer, and with more cognitive deterioration. And yet, the funding and staffing models in the sector are archaic. By legislation, only one RN is required per nursing home in Ontario. Some nursing homes have as many as 300 residents. This is outrageous and unacceptable. Funding models in long-term care penalize nursing homes for improving patient outcomes. RNAO has been going into long-term care homes across this province for many years with best practice guidelines (BPG) that teach regulated and unregulated staff about preventing pressure injuries, preventing falls, managing incontinence, reducing the use of restraints, and so much more. These homes are funded on the basis of complexity of care. This means that when our BPG recommendations are implemented and patient outcomes improve, care becomes less complex and funding is decreased. This too is outrageous and unacceptable. We need to bring funding and staffing models into the 21st century, and a public inquiry will help us do that. We also need to delve more deeply into when and how regulatory colleges tackle disciplinary issues. We now know that Wettlaufer was fired in 2014 for making a number of medication errors, but was not investigated by CNO at that time. A disciplinary hearing this July also revealed the former nurse was investigated for stealing medication in 1995. How was she able to continue to practise despite these red flags? We need to muster the courage to look in the mirror and learn. The tragic murders of eight Ontario seniors will forever remind us that health professionals are in a very privileged position. Nurses enjoy higher public trust than any other profession. We must cherish that trust by leaving no stone unturned. This public inquiry is our collective opportunity to do just H that. n
Doris Grinspun, RN, MSN, PhD, LLD (hon), O.ONT, is chief executive officer for RNAO. Follow her on Twitter @DorisGrinspun This column was originally published in the July/August issue of Registered Nurse Journal 2 Hospital News SEPTEMBER 2017
Contents September 2017 Edition
IN THIS ISSUE:
Bacteria killing robot
s Bedside allergy test for penicillin
Nursing Pulse ...................2 Guest Editorial ..................4 In brief ...............................6 New stent expands treatment options for critically ill ....................8 Transforming emergency access .........10 Infoway Partnership Conference .....................20 Rapid-access addiction clinic ...............22 From the CEOs desk .......25 Evidence Matters ...........26 Improving healthcare for prisoners .........................27 HN Podium ......................28 Product spotlight ...........30 Events .............................30 Careers ...........................31
s Cover story: Preparing for disaster â€“ Are we ready yet?
s Injured teen reunites with paramedics who saved her
s Online learning: Made for physicians
s Life-saving rehab care
Making progress Dr. Joshua Tepper
arlier this year at the annual meeting of the Canadian Association of Radiologists, a former president of the Canadian Medical Association described wait times for medical services as “a horrible disease.” About the same time, leading medical journalist Andre Picard wrote that “Canada has some of the longest waits for medical care in the developed world” and called them “a badge of shame.” His comments were based on data from the Commonwealth Fund’s 2016 International Health Policy survey showing that Canada lagged behind 10 other developed countries when it came to receiving timely access to healthcare. The Institute of Medicine considers Timeliness one of the key dimensions of quality (dimensions which have been adopted here in Ontario by Health Quality Ontario). Finally, federal and provincial governments have spent billions of dollars on efforts to improve wait times. These examples demonstrate why wait times have sometimes become a surrogate for the state of the Canadian healthcare system. “Waiting for treatment has become a defining characteristic of Canadian healthcare,” is how the right leaning Fraser Institute once described it. While some waits may be just a few days or weeks and be considered reasonable, they can often be much longer. Take the recent case quoted in a Healthy Debate blog of Nancy who has waited 16 months to see a rheumatologist and has been told there’s a two-year wait to a pain management centre to help with her chronic pain, while her husband waited 160 days for a referral to a gastroenterologist after having daily nausea, vomiting, upper abdominal pain and exhaustion.
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Despite wait times being such an important touchstone issue for our healthcare system for many years, we lacked readily available and complete data to discuss wait times and develop solutions. Instead, we have relied on anecdotes such as Nancy’s story above. In fact, the Fraser Institute which is known for publishing worrisome statistics about wait times on an annual basis was criticized last year for the voluntary and incomplete nature of its data. Ontario has spent more than a decade on improving its publicly reported wait times data. In 2005, the Wait Time Information System was created to collect accurate and timely wait time data in the province for the first time on the time patients wait for surgery or diagnostic testing. Since that time, Ontario has publicly reported access to care performance against wait time targets for surgical and diagnostic imaging services. Subsequently, the Wait Time Information System was expanded to all surgical services and now includes Emergency Room wait times, Alternate Level of Care bed utilization and efficiency, as well as operating room efficiency targets. Data is being collected from more than 100 hospitals and 3,500 surgeons. To quote Dr. Jonathan Irish, who is Provincial Clinical Lead for Access to Services and Wait Times and provincial head of the Surgical Oncology Program at Cancer Care Ontario, this “allows near real time reporting on a monthly basis about how our system is reacting to the needs and demands of Ontario patients. The system also allowed us to establish guidelines, standards and targets to better triage the delivery of care.” Continued on page 7
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Bedside allergy test increases number of patients receiving penicillin By Sybil Millar atients who have previously reported a penicillin allergy are often able to receive the drug after a simple bedside skin test, a new study led by Sunnybrook has found. “The majority of patients who report an allergy to penicillin could likely tolerate it if they received it. Doing a bedside allergy skin test helped us determine who those patients were,” says Dr. Jerome Leis, lead study author and Medical Director of Infection Prevention and Control at Sunnybrook Health Sciences Centre. “Many people outgrow their penicillin allergy, or may be able to receive the drug in controlled doses.” Pharmacists were trained to perform beta-lactam allergy skin testing (BLAST) at the bedside of hospitalized patients, which included a prick test with a small amount of the penicillin on a patient’s skin. Antibiotics from the beta-lactam family, such as penicillin, are the preferred (and some-
times, only) treatment for many serious bacterial infections. Thirty minutes after the skin test, if the patient showed no signs of an allergic reaction, such as swelling or a rash, they were then given a test dose of the drug. If no further reactions were observed after four hours, the patient then received the preferred penicillin-based treatment for their infection. The multicentre study, which included three hospitals in Toronto, was a collaborative effort between antimicrobial stewardship, allergy, infectious diseases and pharmacy experts. Of the 85 patients identified to receive BLAST, 83 (99 per cent) were switched to beta-lactams such as penicillin and finished their course of treatment without complication. The results of the study show that bringing skin testing to the bedside improves treatment of serious infections. “In the past, we haven’t had the evidence to support skin testing, but this study has shown us what a positive difference bedside skin testing can make,” says Dr. Leis.
The study findings are particularly important for patients with life-threatening infections that are best treated with penicillin. One in 10 Canadians report having a penicillin allergy, meaning those patients may receive less effective antibiotics to treat their infections and experience poorter outcomes as a result. “In addition to some of the more toxic side effects associated with alternate therapy to penicillin, some of these alternative drugs don’t reach the site of infection. Limiting the use of those alternate therapies also reduces antibiotic resistance,” says Lesley Palmay, study co-author and Infectious Diseases Consult Service Pharmacist at Sunnybrook. As a result of the study, which was published in the Clinical Infectious Diseases Journal, Dr. Leis says bedside skin testing is now a standard practice at Sunnybrook. “Now, the right patient can receive the right antibiotic for their infection, without fear of an allergic H reaction.” n
Sybil Millar is a Communications Advisor at Sunnybrook Health Sciences Centre
SEPTEMBER 2017 Hospital News 5
Researchers test new technique to help with concussion diagnosis The Odette Cancer Centre Central Nervous System radiation oncology team at Sunnybrook Health Sciences Centre. The Gamma Knife Icon works by focusing hundreds of radiation beams on a single target.
First in Canada: Gamma Knife Icon targets brain metastases
his June, the Odette Cancer Centre Central Nervous System radiation oncology team at Sunnybrook Health Sciences Centre became the first to use the Gamma Knife Icon to target brain metastases. The Gamma Knife delivers focused radiation to tumours that have spread (metastasized) to brain. The frameless Gamma Knife Icon uses a mask instead of a head frame to secure the patient while radiation beams carefully target the brain tumours. Sunnybrook is
the first hospital in Canada to use this machine. “After years of planning and fundraising, we are excited to be the first hospital in Canada to have installed and treated our first patient with Icon. The system allows us to offer our patients highly precise treatment and a more comfortable experience,” says Dr. Arjun Sahgal, radiation oncologist and the head of Odette’s Cancer Ablation Therapy program. “This opens the door to a whole new world of H treatment options.” n
ports-related concussions are a major public health concern and are notoriously difficult to diagnose. But new research from UBC’s Okanagan campus provides a new tool to help test athletes for recent brain trauma. “Diagnosing concussions relies heavily on patients reporting their symptoms. While there are other tests that may be used to help clinicians make a diagnosis, they can be extremely subjective, inaccurate and, frankly, easy to manipulate,” says study lead author and UBC Okanagan medical student and PhD candidate Alexander (Sandy) Wright. “Because concussions can’t be seen on standard brain imaging, the holy grail in the concussion world has been to devise a test that can objectively say whether or not a patient has suffered a mild brain injury.” Using ultrasound equipment to measure the speed of brain blood flow,
Wright and his collaborators in the School of Health and Exercise Sciences, measured the blood flow response to increased brain activity in the brains of 179 junior-level athletes before the athletic season. Athletes who sustained concussions during the season, completed the testing again at three time points after injury. Researchers found a clear link between the brain injury and changes to the brain’s blood flow response that were related to how long the athletes were sidelined from competition. Wright says that this technique may one day help determine what degree and what type of concussion an athlete may have. Ideally, he says, researchers will assemble a series of tests that will help objectively diagnose the injury and also provide some prognostic value and give clinicians an idea of how long brain healing might take. Wright’s research was recently published in the H Journal of Neurotrauma. n
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Prolonged standing on the job more likely to lead to heart attack than prolonged sitting
orkers who stand on the job most of the time are at greater risk of heart disease than workers who predominantly sit. According to a study published in the American Journal of Epidemiology, even after taking into account a wide range of personal, health and work factors, people who primarily stand on the job are twice as likely as people who primarily sit on the job to have a heart attack or congestive heart failure. The study followed 7,300 workers aged 35-74 from Ontario, Canada (who were initially free of heart disease) for 12 years. These workers were respondents to the 2003 Canadian Community Health Survey (CCHS), which collected information on personal factors, health conditions, health behaviours and work conditions. It also collected job title information, which was used to estimate if a job primarily involved sitting, standing/walking, a combination of sitting/standing/
Workers who stand on the job most of the time are at greater risk of heart disease than workers who predominantly sit walking or other body posture (such as bending or kneeling). Among the group included in the study, nine per cent were estimated to predominantly stand at work, and 37 per cent were estimated to predominantly sit. The researchers then linked the CCHS information to administrative health records housed at ICES to identify people who had a new case of heart disease over the next 12 years (2003-2015). During this period, 3.4 per cent of the study group developed heart disease—more men (4.6 per cent) than women (2.1 per cent). Without taking any other factors into account (the unadjusted risk), the risk of heart disease was higher among people whose jobs required mostly standing (6.6 per
cent) than among people whose jobs involved mostly sitting (2.8 per cent). Even after adjusting for a wide range of factors— personal (e.g. age, gender, education levels, ethnicity, immigrant status, marital status), health conditions (e.g. diabetes, arthritis, hypertension, mood and anxiety disorders), health behaviour (e.g. smoking, drinking, body mass index, exercise) and work (e.g. physical demands, shift schedule) — the risk of heart disease was still twice as high among people who primarily stood on the job compared to those who primarily sat. In fact, the unadjusted risk of heart disease among people who stood on the job (6.6 per cent, as mentioned above)
was even slightly higher than among daily smokers (5.8 per cent). “A combination of sitting, standing and moving on the job is likely to have the greatest benefits for heart health,” says Smith. “Workplaces need to apply this message not just to workers who predominantly sit, but also – in fact, especially – to workers who predominantly stand.” That says, workplaces need to look beyond physical job activity to truly protect the cardiovascular health of workers, Smith adds. While jobs that involved a combination of sitting, standing and walking were shown in this study to be associated with a decreased risk of heart disease among men, these jobs didn’t result in a decreased risk among women. Smith suspects this is due to the fact that nurses and teachers accounted for most of the jobs held by women in the “sitting, standing and walking” category, jobs known to be H stressful in different ways. n
Continued from page 4
Making progress Despite that progress, one key missing element of the wait times picture in Ontario was the absence of Wait 1 data: the time from the date of referral to a specialist from a primary care provider to the date of first consultation with a specialist. Ontario is only the second jurisdiction in Canada to now publicly post such data. The data is available in an easyto-read format on the Health Quality Ontario website and supports our mandate to monitor and report to the people of Ontario on access to publicly funded health services. Posting of wait times data is a collaboration between Health Quality Ontario, Cancer Care Ontario, CorHealth Ontario and the Ministry of Health and Long Term Care. Access to the Health Quality Ontario site can also be made via Ontario.ca/health.
Providing wait times data in such a transparent fashion will support better accountability and improvement. Unfortunately there are important limits in the quality and application of this data that we should work to resolve. These include measuring the full wait a patient experiences from symptoms to seeing a specialist and/or having treatment; the waiting experience for patients who do not go on to have surgery; and the wait times for other specialties beyond surgery such as psychiatry. Dr. Irish comments: “Reporting on wait times does not answer the question of whether such wait times are excessive and cannot on its own reduce wait times. But it does provide the necessary, accurate and accessible information to all stakeholders, public, providers and policy-makers alike to H target improvement efforts.” n
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Dr. Joshua Tepper is president and CEO of Health Quality Ontario www.hospitalnews.com
SEPTEMBER 2017 Hospital News 7
New stent expands treatment options for critically ill patients By Kelly O’Brien astroenterologists at St. Michael’s Hospital were the first in Ontario to use a new type of stent to treat complicated cases of pancreatitis and severe infection in the bile ducts or gallbladder. The stent also allows gastroenterologists to treat patients at the bedside using an endoscopic ultrasound, expanding treatment options for those in the intensive care unit who are too sick to be moved or to have major surgery. The stent, known as a Hot-AXIOS stent, is used in the United States and Europe, but is not yet approved for use in Canada. St. Michael’s was the first hospital in Ontario to get “batch approval” from Health Canada for eight
Did you know? St. Michael’s was the first hospital in Ontario to get approval to use a new type of lumen apposing self-expanding metal stent
stents, to be used where doctors otherwise wouldn’t have been able to treat the patient. Dr. Jeff Mosko performed the first procedure using the stent in January, alongside Dr. Gary May, division head of gastroenterology at St. Michael’s. Both participated in specifPhoto by Yuri Markarov
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Dr. Gary May performs an endoscopy at St. Michael’s Hospital. A new stent will allow Dr. May and other gastroenterologists to expand the number of patients on whom they can operate using a scope. er to prevent dead tissue from leaking ic training before being granted the into the body when draining the cyst, batch approval. which reduces complications. “This stent allows us to expand the Dr. May says there were some huge number of patients we treat and reducadvantages to using the new stent. es the number that need major surgery “It facilitates further treatment, and because we can operate through the allows for the procedure to be perscope on patients who we wouldn’t formed in one step,” he says. “When have been able to before,” says Dr. May. extra steps are eliminated, it reduces Pancreatitis is a condition in which the time for the procedure, and it can the pancreas becomes inflamed, and in be done without the need for X-ray, severe cases, can cause fluid and dead which opens up the options of where tissue to collect in the form of cysts we can treat the patients.” near the stomach. The fluid and tissue But there are disadvantages, the are relatively easy to remove using a main one being the cost. The Hot-AXtraditional plastic stent and a scope, so IOS stent is significantly more expenlong as the cyst and stomach are stuck sive than other stents. together. “It’s not something we’re going to The Hot-AXIOS stent is a lustart using in every case, but certainly men-apposing metal stent, or LAMS, we can use it when we can’t proceed made of a coated woven metal alloy with our standard techniques, or usinstead of plastic. Its shape, similar to ing this stent would significantly minthat of a dumbbell, allows it to be deimize the risks for the patient,” says ployed through an ultrasound scope. H Dr. May. n It brings the stomach and cyst togeth-
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A HUB of innovation transforms emergency access E
very year, St. Paul’s Teck Emergency Centre sees more than 10,500 patients with mental health and substance use issues – the highest number of any Emergency Department (ED) in BC. In some cases, police escort the person in need of emergency care, which means officers must wait with them until they see a doctor. On average, this takes 75 minutes. In 2015, to help alleviate the mental health and substance use crisis and reduce these wait times, the Vancouver Police Department and Vancouver Police Foundation approached St. Paul’s with an idea and an anonymous donation of $750,000. Jennifer Duff, then-director of the mental health program at Providence Health Care and Dr. Bill MacEwan, then-director of psychiatry at St. Paul’s, set about examining the issues and possible solutions. With limited options, including lack of space and the future move to a new hospital site, Duff and MacEwan brought in more partners to come up with a unique and innovative solution. To raise the $3.5 million in capital costs required for the project – to be named the HUB – St. Paul’s Foundation has committed to raising $1.75
How will the HUB help? •The HUB will care for an estimated 6,000 patients each year •P rovide a more integrated care model between acute and community services; •R educe readmission rates to the ED •R educe police wait/handover times to a 20-minute average million to match the initial anonymous gift of $750,000 and $1 million in funding provided by the City of Vancouver.
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The new St. Paul’s Office of Innovation also stepped up to help during this crucial time. Together, in fall 2016, they came up with a solution that would unite emergency care, rapid access to treatment and a transition centre, to provide better and faster care for this vulnerable population. The HUB will consist of three parts: 1. Housed in a custom, redeployable modular unit connected to the ED, the clinical HUB will be a state-of-the-art clinical treatment area staffed by nurses and physicians with special training in mental health, substance use and emergency care. 2. The Rapid Access Addiction Clinic (RAAC) is located on the second floor of the hospital. There, substance use patients are assessed and started on appropriate treatment within 24 to 48 hours after referral. 3. The Vancouver Police Foundation Transitional Care Centre adjacent to the ED, where discharged pa-
tients can decompress, prepare to transition back to the community and get help connecting to vital services. “It can be a shaming experience to access care,” says Scott Harrison, director for strategy and transformation, urban health, mental health and substance use at St. Paul’s. “The HUB will allow people to be triaged to an environment that is much more therapeutic – one that promotes dignity,” he says. Through the HUB and future care models, the Office of Innovation will continue to enable ways to improve both the quality of care and health outcomes for patients. “We’ll have changed the way we provide care and transition this population forever,” says Duff of the HUB model. To do it in under a year is a feat of modern health, one that would not be possible without the partnerships and innovation pathways that St. H Paul’s fosters. n
This article was originally published in the Spring/Summer issue of Promise, St. Paul’s Foundation’s magazine. Be a part of bringing this transformational care model to our community. Donate now at helpstpauls.com/HUB www.hospitalnews.com
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Life-saving rehab care By Michael Oreskovich
wenty per cent of seniors who break a hip die within a year due to post-operative complications, according to a 2010 report from the Public Health Agency of Canada. Runnymede Healthcare Centre addresses this serious health risk to Ontario’s seniors by providing a safe bridge to home through the Low Tolerance Long Duration Rehabilitation (LTLD Rehab) program. For 75-yearold Luisa Soares, the specialized level of care Runnymede provides wasn’t just essential to her recovery – it was life-saving. Last summer, Soares fell in the garden of her Mississauga home, breaking her hip and fracturing her wrist. The independence that the 75-year-old had enjoyed her entire life was suddenly thrown into uncertainty. After her fractures were surgically treated in an acute care hospital, Soares was admitted to Runnymede’s LTLD Rehab program. Soares was far from alone in her healthcare needs; the Public Health Agency report states that about 40 per cent of all fall-related hospitalizations among seniors involve hip fractures. In addition to causing a decline in overall quality of life and potentially reducing life expectancy, these injuries
Runnymede’s LTLD Rehab program provides continuous medical supervision to patients who are at risk of suffering life-threatening complications during recovery from injury or surgery in acute care. also increase the likelihood of longterm hospitalization. Since 2012, the LTLD Rehab program at Runnymede has helped over 1,500 patients transition back to the community after injury or surgery in acute care by providing low-intensity rehabilitation. In the fall of 2016, Runnymede strengthened its focus on
rehabilitation by attaining an official designation as a rehabilitation hospital, enabling it to build on its strengths and expertise and expand the level of its services. Patients in the LTLD Rehab program receive continuous medical supervision, which helps minimize the impact of complications that could arise during their recovery. This level of care proved to be vital to Soares while at Runnymede, even though it wasn’t immediately apparent. “When she was first admitted, Luisa seemed like the ideal rehab patient,” says Elisabeth Despres, Runnymede’s professional practice leader – allied health and pharmacy. “Although she couldn’t stand or walk due to her injury, our team was confident that we would meet her goal of returning home within a few weeks.” After making strong gains early in her recovery, Soares reported feeling dizzy and drowsy. “We were alarmed because we thought it could be a symptom of a bigger problem,” says Van Nguyen, physician assistant at Runnymede.
The interprofessional team responded immediately by collaborating with an acute care partner to diagnose Soares’ condition. A CT scan confirmed the presence of blood clots in the major blood vessel in her lungs. “The formation of these clots in the lungs is a common post-operative complication, which is potentially life-threatening because they block blood flow to the lung,” says Nguyen. After one week of treatment in acute care, the severity of Soares’ symptoms subsided and she was readmitted to Runnymede. Upon her readmission, Soares was like an entirely new patient. “Her condition was very serious so we monitored her carefully and helped her stabilize,” says Nguyen. “Our focus was on getting Luisa well enough to resume her rehab.” The physiotherapy and occupational therapy teams’ focus also needed to shift in order to meet Soares’ new challenges; their treatment plans were revised according to her needs. “Luisa couldn’t tolerate the same level of rehab as before, so we worked with her to set new goals,” says Despres. “We had to go back a few steps and work on simpler things, like getting out of bed.” The road to recovery isn’t always a smooth one. For patients recovering from injury or surgery – seniors in particular – life-threatening complications can arise over the course of their rehabilitation. Runnymede’s LTLD Rehab program addresses this risk by providing patients with around-theclock medical supervision that exceeds what is available either at home or in a community care setting. For Soares, the extended rehabilitation and continuous medical supervision paid off. Three months after her injury, she was back at home and had resumed her independence. Prior to her discharge, the physiotherapy team made arrangements with a healthcare facility near Soares’ home to ensure she would get the necessary follow-up treatment in her community – as a matter of fact, she even drives herself H to get there. n
Michael Oreskovich is a Communications Specialist at Runnymede Healthcare Centre 12 Hospital News SEPTEMBER 2017
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Are we ready yet? By Dr. Daniel Kollek and Dr. Carl Jarvis even years ago I was asked to write an article for a hospital management magazine on disaster preparedness. The question was: “Are we ready?” Now, while preparing this review, I thought it might be appropriate
to see how things have changed since. Unfortunately, problems still remain. I may have been saved some re-writing, but my preference would have been to tell you a different story. It would be unfair to say there’s been no effort or improvement since 2010;
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there have been changes. New hospital builds now incorporate de-contamination into some of their emergency departments: large gatherings such as Toronto’s G20 served as a springboard to improve hospital readiness: some cities such as Montréal – driven by dedicated local leadership – conducted more frequent disaster exercises: and disaster content is showing up more frequently at ”mainstream” conferences. Leading major centres (including Ottawa and McGill University hospitals), are changing their corporate emergency preparedness structure to a clinical-administrative dyad model to help bridge the gap between those with clinical and those with organizational skills (more on this divide later). That says, the core issues remain unchanged. Hospitals are not performing formal risk assessments and disaster plans are not reviewed and measured against formal standards. Where functional hospital disaster plans do exist, they’re rarely exercised, with poor integration between hospitals and pre-hospital/ disaster site response.
So what’s impeding change?
The recurrent theme remains that when one is further away from the actual delivery of disaster care, the better prepared the system is perceived to be. The discrepancy of readiness perception between high and mid-level administration and frontline caregivers stems from a variety of reasons. The simplest explanation is the gap in training and expertise (and in some situations actual physical distance) between the administrator and the individuals mandated to deliver disaster-setting care. As a striking example of this, in 2010, the Canadian Association of Emergency Physicians contacted provincial health ministers across the country to voice concern about the healthcare system’s ability to respond to disaster. Uniformly, the provincial health ministers who responded (8 of 10) stated that their provinces were prepared. This despite any scientific data to support their opinion. www.hospitalnews.com
COVER Unfortunately, the reality at the front lines is not so rosy. Front- line providers have repeatedly expressed serious concerns about the ability of healthcare systems, and specifically healthcare facilities, to respond in a disaster. Staff are inadequately trained, despite the existence of competency lists and curricula. U.S. data show a wide variability between regions and facilities. Canadian data, while limited for reasons that will be expanded on further, also show there are both regional and topic specific areas of strengths and weaknesses for specific types of events. One reason for this lack of preparedness is the perception that attacks such as those in London, Manchester, Paris, Brussels and Nice will never happen here. There is no basis for this belief, even if it were true. From the receiving hospital’s viewpoint, it doesn’t matter whether the patient’s injury was the result of a malicious terror attack or an accident. Claiming a low terror risk is no protection from other accidents and, even if it were, Canada is not at particularly lower risk than other western nations.
to do so. For example, Israeli hospitals – likely the world leaders in preparedness for dealing with disasters – have developed standard operating procedures that facilitate the management of mass casualty incidents. This is as applicable to a bus crash as to a less likely terror event (more on this later). Since there are standards against which to measure performance, it is possible to define what constitutes an organized response to a disaster and equally possible to develop an ongoing process of quality improvement. Incidentally, the statement that there’s a large variability in potential disasters leads one to ask why hospitals don’t routinely perform risk assessment to determine which disasters may befall them. Currently, there is no evidence that any formal risk assessment tool has been deployed across hospitals in Canada. It doesn’t help that, particularly in healthcare, disaster preparedness is an “orphan” entity. Healthcare professionals have extremely limited training in disaster preparedness: disaster management experts have almost no expertise in healthcare, and there is no
Hospitals are not performing formal risk assessments and disaster plans are not reviewed and measured against formal standards Disasters do strike. The question is not “if and why” but “when and where”. A Wikipedia search, for example, will reveal that in 2016 alone, there were 61 significant train derailments globally, of which 13 were in North America. The chances of someone being involved in an accident are far higher than a terror event, so the argument that terror events are uncommon provides no justification for lack of readiness for mass casualties. Another oft-quoted reason for not having a disaster assessment tool is that disasters are so variable that it’s impossible to test our readiness for them. While it’s true that disasters may vary, the general response to disasters is uniform and is frequently termed “all hazards” preparedness. Since, at least in general terms, we know the response we need to deliver, we can develop protocols and test our ability www.hospitalnews.com
overarching authority able to bridge the gap between the two. This diffusion of responsibility exists at all levels, but reaches an extreme at the federal level. The Minister of Public Safety has the expertise and tools for disaster response, while the Ministry of Health has significant knowledge of health care issues at its disposal, yet both lack each other’s proficiency. Political considerations are another possible reason we’re ill equipped. So far as previous Federal administrations are concerned, disaster preparedness isn’t a voter “hot button” issue and therefore receives limited support from elected officials. Further, the federal-provincial divide on healthcare issues is problematic. Front-line delivery is a provincial mandate, and this makes it difficult for federal agencies such as the Public Health Agency of Canada (PHAC), to effect change at the provincial level despite very signif-
Disasters do strike. The question is not “if and why” but “when and where” icant effort, much goodwill and solid expertise on their part. The final reason high-level healthcare leadership thinks we’re ready for disasters is that nobody has actually checked. There has been no formal, replicable and evidence-based assessment of disaster preparedness at healthcare facilities in Canada. If we do not measure our inabilities, we will not be able to remedy them. This underpins all other problems. This is despite the fact Canadian tools do exist for both risk and readiness assessment. With support from the PHAC, The Centre for Excellence in Emergency Preparedness (CEEP) has developed and presented such tools in multiple forums since 2003. These were even offered free of charge to Accreditation Canada, a for-profit company that sells its product (certification) to hospitals and systems that choose to participate. Accreditation
Canada develops their checklists, with standards they themselves derive, based on a general agreement between their clients (hospitals) and Accreditation’s opinion of which systems are needed to meet a target goal. The company has no evidence based clinical standard of preparedness for Mass Casualty Incident (MCI) events and they declined the offer of an outside tool. As a result, a Canadian hospital can be accredited without any indepth disaster-readiness. Why the reluctance to formally and scientifically assess hospitals for disaster preparedness? The obvious (never-voiced) risk is, should a deficiency be found, deniability is no longer plausible – and resources would be needed to repair the gaps. An additional argument for the lack of formal disaster readiness assessment is the lack of a standard of care. Canada has no national clinical standards for emergency preparedness. Continued on page 16
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Are we ready yet? This was the unfortunate conclusion of a 2013 conference in Ottawa sponsored by PHAC, and the situation hasn’t changed since.
outcomes of events and exercises, we’ll never know what works in our system, never develop guidelines and never learn what we should aspire to.
Disasters, despite the fact that they cause morbidity and mortality like any other disease, are the only clinical scenario with no guidelines It’s true that there are regulatory and accreditation standards (as mentioned above). There are also occupational health standards, and, for some specific scenarios, clinical best practices. Disasters however, despite the fact that they cause morbidity and mortality like any other disease, are the only clinical scenario with no guidelines. As a result the argument is made that, because there are no guidelines, we cannot prepare adequately. This is circular logic. Until we start developing and testing plans as well as measuring
In the meantime, rather than bemoan a lack of Canadian disaster response standards, we should be learning from other countries. Through the offices of American friends of MDA (the Israeli pre-hospital system), Israel offers annual courses on how to prepare the hospital and pre-hospital system for disaster. Closer to home, the rapid intake of patients at Boston hospitals during the 2013 marathon bombing, the almost immediate mobilization of 60 ambulances in Manchester to the Ariana Grande attack this year, or the rapid deployment
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of outreach care during the attacks in Paris recently provide further examples of how this can be done – and done well. In an interview with CMAJ (Canadian Medical Association Journal) Dr. Ron Walls, Chief of Emergency at Boston’s Brigham and Women’s Hospital is quoted as saying: “We had drilled this exact scenario, this idea of having a bomb going off in a mass gathering in town. Nobody is ever prepared for this, but we were prepared. I would just suggest to people that if they think these drills are silly or unnecessary or that this can’t happen – it can happen.” Canadian hospitals need to learn from these examples, develop adequate plans and, above all, exercise their response. There’s no substitute for real world practice. In the United States, disaster-readiness is tied to Federal funding so an unprepared hospital suffers a financial impact. No such legislation exists in this country.
understandable. Faced with pressing and immediate issues, including hospital overcrowding and budget management, potential problems such as disasters are seen as deferrable concerns. The irony is that, with our alternate level of care (ALC) statistics, our blocked emergency departments and overwhelmed pre-hospital services, the disaster is upon us already. We are blinded to it because it arrived with a whimper, not a bang. Even more ironic is the fact that good disaster preparedness may prove helpful in dealing with overcrowding. Because disaster response is an organization-wide process, its improvement has an impact on the entire hospital. If disaster is defined as an event that outstrips the organization’s ability to deliver healthcare, preparedness is a method of “vaccination”. Processes discovered to be useful in expediting care in a disaster situation raise the threshold not only under these condi-
We had drilled this exact scenario, this idea of having a bomb going off in a mass gathering in town. Nobody is ever prepared for this, but we were prepared The situation is even worse when considering events with contamination. Occupational health standards do exist for staff caring for patients in hazardous materials (hazmat) situations. At the very least, staff are not supposed to put themselves in harm’s way when safety measures (equipment, training, and drills) could reasonably be undertaken to keep them safe. We have to recognize that the lack of preparedness for contaminated casualties is a choice some hospitals have made. Many hospitals are so far below that basic level of due diligence that the only safe option for nurses and physicians confronted with a contaminated casualty would be to stand by and wait for a hazmat team to arrive. Indeed while some Canadian hospitals have undertaken innovative programs to train their staff in managing such casualties others have chosen to contract out their decontamination. The final reason hospitals have not assessed their readiness is the most
tions, but can easily find their way into the general day-to-day function of the organization. Hospitals that function well prior to an event may have even less need to invoke their disaster plan to begin with. Beyond the morbidity and mortality that disasters can engender, these events pose another risk to healthcare facilities and systems. High-profile lack of preparedness puts hospitals at risk for both reputational damage and lawsuits. In today’s 24/7-news-cyclemobile-phone-video world, disasters and the response to them are very visible to the public. An organization that responds poorly to a severe event can tarnish its reputation for an extremely long period of time. Any mention of the Federal [U.S.] Emergency Management Agency (FEMA) today immediately brings to mind their mismanaged response to Hurricane Katrina, while all the good works FEMA performed in the past are forgotten. Continued on page 31 www.hospitalnews.com
Online learning – made for physicians By Holly Clark
f you are a physician, you are also quite likely used to making sacrifices. It starts with an immense amount of education. Then, the job is tough – one of the toughest. Your social calendar? It could not be scarcer. To top it all off, despite everything you’ve learned in medical school, there is a lot of onthe-job learning you are expected to undertake. Confidence isn’t one of the things you should have to sacrifice. That’s where online learning can help. It’s almost as though it was created for physicians. Life-long education is a must for physicians. The benefits of in-person courses are obvious – you’re immersed in it, you’re with your colleagues, you have face-to-face discussions with facilitators and instructors. The value of online learning is high but not always quite as clear. It lies within the fluidity of it all, the flexibility, the opportunity for physicians to pick and choose their
Online learning teaches physicians to be self-directed, and in a career that demands leadership, that is one crucial skill education as they see fit so they finally feel like they can take their time, as opposed to cramming things in. The biggest advantage though, is that it teaches physicians to be self-directed, and in a career that demands leadership, that is one crucial skill. “These courses are designed for the self-motivated,” says Jennifer Wickenden, Senior Advisor of Physician Leadership and Development at Joule. “They are often more convenient but a learner still has to push themselves.” Jennifer is responsible for development and delivery of online courses at Joule, the Canadian Medical Association’s newest company, and she says that it is only normal for physicians
18 Hospital News SEPTEMBER 2017
who have taken an online course to not fully understand what it will be like. When you’re used to the traditional education cycle, online learning is an adjustment, but she says physicians are always pleasantly surprised. Primarily, they are impressed with the insidious benefits that arise from such in-depth courses. “It’s a very different type of learning,” she says. “You take a course over a sixweek period, so you have the chance to take little bits of knowledge gradually, test them out in the real world, reflect and give critical thought to what you’ve learned before coming back.” Another benefit, Jennifer says, is the unique kind of online camarade-
rie that occurs with online courses. “Physicians have says this is a great way to network,” she says. “They meet once a week in live webinars where they can discuss what they learned, bring their own challenges to the table, but the conversation keeps going afterwards.” Providing an online sphere for Canada’s brightest medical minds to discuss such challenges is monumental, Jennifer says, to the future of healthcare. “Every province has its different perspectives on healthcare,” she says, “It’s so interesting to hear people come together and form best practices. Having these online courses is a great way to continue building those contacts across the country.” The most noticeable advantage however, not surprisingly, is the flexibility of online courses. With demanding work schedules, patient loads and family lives, physicians can’t always carve out two-three days to travel for
face-to-face courses. In a career filled with set schedules, online learning lets physicians prioritize their time the way they want to. “I had one doctor tell me she was taking an online course while on vacation in France,” she says. “They can manage their learning with everything else they have going on.” The plethora of online material is expansive, but Jennifer says she enjoys developing courses catered specifically to making physicians better leaders. With courses in self-awareness training, effective communication and financial acumen, Joule highlights the everyday lessons you can’t get in medical school. “Physicians take these courses and have so many light bulb moments about themselves,” she says. “They are so focused on that clinical piece
in medical school; they miss out on all these other aspects of their education, specifically who they are as a leader. In this career, bettering yourself as a leader is one of the most important things you can do.”
Joule, a subsidiary of the Canadian Medical Association, is home to the Physician Leadership Institute, a platform for physician leadership development. With a wide range of online courses, Joule is becoming a major
player in the online learning game. With courses on effective communication and financial management, Joule provides residents and physicians with the tools they need to improve their H practice. n
Holly Clark is Editorial Coordinator, Specialty Publications at Joule
SEPTEMBER 2017 Hospital News 19
Infoway Partnership Conference to emphasize digital health for Canadians By Dan Strasbourg
or the past 12 years, digital health advancement has been at the forefront of the annual Infoway Partnership Conference, which serves as a forum for knowledge exchange, debate and discussion.
In the early years, the conference emphasized modernizing the health care system by moving from paper to digital as the medium to record and exchange patient information. Today, interoperable systems that securely store and may communicate data (lab
in environments that
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test results, digital images, and medication history), among healthcare providers are widely in use. Patients and caregivers can play a crucial role in improving patient outcomes themselves, and they are at the forefront of the next wave of digital health innovation in Canada.
lessons learned,” says Lynne Zucker, Vice-President at Infoway. “Included within the program will be a healthy amount of debate and discussion, as well as a showcase of emerging digital health solutions that will transform the healthcare experience for Canadians, from how care is ac-
Included within the program will be a healthy amount of debate and discussion, as well as a showcase of emerging digital health solutions that will transform the healthcare experience for Canadians This year’s Infoway Partnership Conference has been designed to align with the next wave of the digital health journey, with themes that include the ability for all Canadians to access and manage digital health records, in addition to interoperability (the ability for systems to exchange information securely). The conference, hosted by Canada Health Infoway, will be held November 14 and 15 in Calgary, Alberta, during Digital Health Week. “Those who attend may look forward to learning from, patients, national and international healthcare leaders who will share their digital health journeys, best practices and
cessed, to how apps are being used to manage health to how medication safety is optimized through electronic prescribing.” While Infoway has always collaborated with clinicians, patients, government and others, the organization continues to greatly value the participation of patients and caregivers for the unique perspective they bring to dialogue. Once again, the 2017 Infoway Partnership Conference is proudly Patients Included Certified. To learn more about the program or register for the conference, visit www. Infoway-inforoute.ca, or follow us @ H Infoway #thinkdigitalhealth. n
Dan Strasbourg is Director, Media Relations at Canada Health Infoway www.hospitalnews.com
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First barrier-free rapid access
in downtown Toronto core opens By Magdalena Stec wo people die from opiate overdoses each day in Ontario and the numbers are growing. Across Canada, we are now in the midst of an unprecedented opiate crisis. To combat the growing problem, Women’s College Hospital (WCH) recently opened a Rapid Access Addiction Medicine (RAAM) clinic where patients who are addicted to alcohol, opioids or other drugs are seen within one to three days, without a booked appointment and without a physician referral. The WCH clinic is the first barrier-free rapid access addiction clinic in the Toronto core that accepts all patients, including self-referrals and walk-ins, in addition to referrals from family doctors, hospitals and emergency departments, and the community.
emergency-room visits and inpatient stays for people with addictions, and saved the healthcare system approximately $200,000 for the first 150 patients in just their first 90 days of treatment. “Typically, patients in crisis end up at emergency departments where they often don’t get the treatment they need. This clinic model has been shown to help save lives by engaging people with short- and long-term treatments as soon as they are ready and interested,” says Kate Hardy, META:PHI project manager, WCH. Tracy Shillington is one of the patients who accessed WCH addiction treatment services. “I was able to walk in, see the doctor right away and get medication all on the same day,” says Shillington. “This has
WCH clinic closes the gaps in care for patients with alcohol or opiate addiction by offering expedited access to lifesaving treatment “Our clinic is unique because we provide immediate access to lifesaving treatment by offering same-day counselling and addiction medication, and we give patients prescriptions to take home,” says Dr. Meldon Kahan, medical director of substance use service, WCH. “The opiate crisis we’re seeing now has reached epidemic proportions, and this treatment offers us a realistic and effective response to this crisis.” The clinic is one of five new rapid-access clinics that will open in Toronto over the coming months under a provincial META:PHI (Mentoring Education and Clinical Tools for Addiction: Primary Care-Hospital Integration) initiative, also based at WCH, which over the last year developed seven rapid-access clinics across the province. The initial seven clinics prevented opiate overdoses, reduced
made the difference between life and death for me.” Recent studies show that there were 734 opioid-related deaths in Ontario in 2015, exceeding the number of those killed in motor vehicle accidents. The rise of fentanyl – a powerful opioid that’s 50-100 times stronger than heroin – has likely contributed to the increase in accidental deaths, as it is often added to other drugs to increase potency. And although experts now see opioid addiction across all ages and socioeconomic backgrounds, according to reports nearly 60 per cent of accidental deaths occurred among youth and younger adults who were 15 to 44 years old. The RAAM clinic is part of WCH Substance Use Service/Addiction Medicine and is open Mondays, Tuesdays, H and Thursdays 10 a.m.–12 p.m. n
Bacteria-killing robot joins St. Joe’s cleaning team By Amber Daugherty hen you visit the hospital, you’re there to get healthy – not to catch something that makes you sicker. But more than 220,000 people get hospital-acquired infections every year in Canada because of being in close proximity to others who are ill. It’s important that healthcare teams continue to evolve their cleaning practices to prevent the spread of bacteria in hospitals so that patients recover faster and staff members stay healthy. At St. Joseph’s Health Centre Toronto, our environmental services team has introduced a new piece of equipment that’s radically changing the cleaning game. After manually cleaning the room using best practices, our team wheels a machine called the
Tru-D SmartUVC (or “Trudi”) into the room. It uses sensors to calculate how much time it will take to disinfect the room, looking at factors including overall size and objects in the room. Once everyone is out, the door is closed and the machine delivers a precise dose of UVC light that’s known to kill bacteria including influenza, norovirus, C. diff, MRSA and others that can spread through hospital environments. “Introducing technology like Trudi is incredible because it acts as an additional layer on top of the cleaning practices we already have in place,” says Michael Rotstein, Infection Prevention and Control Manager. “It allows us to guarantee our patients and staff that we’re taking an extra step to protect their health.”
Magdalena Stec is Communications Lead, Women’s College Hospital 22 Hospital News SEPTEMBER 2017
focus Left: Carlo Sebasta and Blagica Bosevka have gone through specialized training to use the UVC cleaner to disinfect rooms at St. Joe’s.
How does it work?
When UVC light hits bacteria, it essentially deactivates it, making the bacteria unable to infect or reproduce. Because of the machine’s unique de-
sign, it’s able to cover every inch in a space, even bouncing around corners and underneath equipment – so it can clean an entire room without having to be moved.
“Our staff are specially trained to use this piece of equipment,” says Carlo Sebasta, Environmental Services Supervisor. “And while we’re currently using it in patient rooms, we’re also
Amber Daugherty is a Communications Associate at St. Joseph’s Health Centre Toronto
working on getting it into the Operating Room to do a final disinfection after the suites have been cleaned at the end of the day.” The machine is also being used to clean equipment that’s shared by staff, including mobile work stations and patient tools and supports including wheelchairs and walkers – items that can often be the culprit for diseases spreading between patients in a hospital setting. “When patients are in hospital, they’re impacted by the spaces that they receive care in,” says Sebasta, “so we want to make sure their rooms and any equipment that’s being used on or around them are also contributing to H their recovery.” n
Penticton teen impaled by tree reunites with paramedics who saved her life he phrase “amazing save” doesn’t even begin to describe it. A Penticton high school student struck and pierced though the core of her body by a log, while riding an ATV on Apex Mountain last summer, was reunited with paramedics, and many others, who pulled out all the stops to save her life. During Marissa Lemioer’s late afternoon ATV ride on July 23, 2016, a log eight feet long and four inches in diameter pierced through the front of her ATV, and entered the 15 year old’s abdomen. It exited the other side of her body after coming alarmingly close to vital organs. The log then went through the back of the ATV, leaving Marissa impaled and pinned in the vehicle. With the location on Apex being out of cell phone range, a friend had to rush down the road to call for help. Within 90 minutes, BC Emergency Health Services (BCEHS) Duty Supervisor Glenn Braithwaite and a PENSAR helicopter external transfer system (HETS) team had flown to the remote scene in an Eclipse Helicopter, and arrived at the patient’s side to provide urgent care, while a very delicate extraction began. “This is one the most significant responses that I’ve been on,” Braithwaite says at the reunion in Penticton last March. “In terms of what all of the responders brought to the table that day, everybody had to have their A-game, and everybody brought their A-game. While I was immensely proud of the work everybody did that day, for me it was just another example of what our crews, dispatchers and support staff are capable of, and do, every day.” With Marissa trapped by the eightfoot log in her ATV, most of it had to be cut free from either side of the patient, before she could be extricated from the ATV and lifted from the scene by the HETS team, and then taken to another location for pick
(from left) BCEHS and KGH attendees at the reunion – Front row: Dr. Mike Ertel, Kelowna General Hospital, Anne Lemioer (Marissa’s mother), Marissa Lemioer (patient). Middle row: EMD Julie Leslie, Paramedic Barry Nicol, Charge EMD Hardeep Dhaliwal, Duty Supervisor Glenn Braithwaite. Back row: Duty Supervisor Amanda Symchych, Paramedic Doug Finlay, A/DS Shane Thair, Paramedic Arthur Gregoris, Unit Chief Pat Husey, and EMD Tim Flanagan (Mike Biden photo).
In terms of what all of the responders brought to the table that day, everybody had to have their A-game, and everybody brought their A-game up by critical care paramedics Mike McKinnon and Steve Hurley. While the extraction was underway, another ground ambulance crew in Penticton was dispatched to Penticton Regional Hospital to pick up blood that they took to the Penticton Airport for the CCT Helicopter to pick up on their way to the scene. Within an hour and 50 minutes after “Task Force Apex” first arrived;
the patient had been assessed, cut free, longlined out to a nearby site and transferred to a BCEHS air ambulance for transport straight to Kelowna General Hospital (KGH) for life-saving surgery. Today, Marissa is doing well, and with her mother Anne, was reunited with the first responders who are roundly credited with saving Marissa’s life. The reunion on March 16, 2017
was organized by the Kelowna General Hospital Foundation and BCEHS and attended by BC Ambulance Service paramedics and dispatchers, PENSAR first responders and Dr. Mike Ertel, the emergency physician who treated Marissa on arrival at KGH that night. Among the attendees was BCEHS Critical Care Coordinator Tim Flanagan who was working in PTCC that night and helped arrange the air ambulance. He says attending the reunion brought real meaning to his contribution. “By putting a face to what I entered into the computer, I found it to be an emotional experience. I was happy that I went to the reunion for some closure that we H rarely get.” n
This article was provided by BC Emergency Health Services staff 24 Hospital News SEPTEMBER 2017
FROM THE CEO’S DESK
Improving system integration through stakeholder feedback By Dr. Andrew McCallum started my career moonlighting as an emergency physician in a small town hospital. I loved it. Working with few staff and limited equipment made for a challenging and rewarding environment. However, as the only physician on duty, I often had to spend time away from the patient making arrangements for transport. And while caring for patients, I wanted to know that transfer of care and transport to a more appropriate centre could be readily arranged – and quickly. Thus, when I became CEO of Ornge in 2013, I understood Ornge’s central role in connecting patients with care. System integration became a key goal in our 2014-2017 Strategic Plan, where we aimed to collaborate with hospitals, paramedic services and other partners
Dr. Andrew McCallum is President & CEO of Ornge. to make patient transport easier to arrange and more seamless. To that end, we have implemented a number of ini-
tiatives. I’d like to detail some of these. We have instituted a Rapid Estimated Time of Arrival (RETA) initiative.
Critically ill or injured patients need to be transferred to definitive care as quickly as possible. We’ve reduced the amount of information collected for emergent patients. Crews are dispatched virtually immediately, reducing time on the phone. Thanks to hospitals’ feedback, we are now providing an initial ETA during the hospital’s first phone call to Ornge, updated with a more precise ETA as needed. Ornge partners with CritiCall Ontario and Central Ambulance Communication Centres (CACCs) on the Ministry of Health and Long-Term Care’s One Number to Call (ONTC) project. The goal is to enhance access to critical care for inter-facility life or limb patients – transfer to the closest, most appropriate hospital via the most appropriate method of transport. Continued on page 31
A prescription for fluoroquinolones
Cure-all or curse? By Michael Raj and Dr. Janice Mann ost of us, at some point in our lives, have been prescribed an antibiotic to treat an infection. And we’re lucky to have medications so readily available to treat infections that just a few generations ago were often fatal. But like most things in our modern lives, when it comes to antibiotics, we want them to act fast and be easy to take so we can get back to our busy routines. In fact, for antibiotics, we may think “the quicker, the stronger, the better” to cure what ails us, but there may be something amiss with that logic. There are many different classes of antibiotics used to treat different types of bacterial infections. One class, called fluoroquinolones, is able to successfully treat a wide variety of infections and includes ciprofloxacin, moxifloxacin, levofloxacin, norfloxacin, and ofloxacin. They are often prescribed in Canada to treat urinary tract infections (also sometimes called bladder infections or UTIs) as well as to treat common respiratory infections like bronchitis or sinusitis. Fluoroquinolones are generally easy to take – requiring less frequent dosing than some other antibiotics – and they work well to clear these infections, making them a popular choice for healthcare providers. In fact, prescribing of this drug class increases each year. But because a drug is easy to take and works well to treat an infection doesn’t always mean it’s the best choice. It’s also important to consider any potential harms that could result from taking the medication. And when it comes to fluoroquinolones, the list of possible side effects is lengthy, with a recent safety review by Health Canada finding that some of the side effects can even lead to disability long after the medication is finished. Side effects of fluoroquinolones
because a drug is easy to take and works well to treat an infection doesn’t always mean it’s the best choice can include tendonitis (inflammation of the tendons that join muscle to bone) or rupture of a tendon (a partial or complete tear of a tendon); effects on the nerves of the body, leading to symptoms such as chronic pain, anxiety, dizziness and confusion; an overly sensitive immune system; phototoxicity (a sunburn like reaction of the skin in response to light); and abnormal heart rhythms. These side effects can occur within hours to weeks after taking a fluoroquinolone and in rare cases may be permanent. Those most at risk appear to be children under the age of 18, adults over 60, and pregnant and nursing women. So with these risks, and with other antibiotics available, why are fluoroquinolones still so widely used? To better understand this issue, CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – recently conducted a review to understand and explain the experiences and decision-making processes around the prescribing of antibiotics for specific types of infections. CADTH carefully searched the medical literature, reviewed clinical practice guidelines, and conducted a survey of primary care practitioners, including family physicians, nurse practitioners, and pharmacists. The review found that, in general, healthcare providers are aware of the risks posed by fluoroquinolones and the need to carefully balance the potential benefits of the medication with those risks. Family physicians, nurse practitioners, and pharmacists
all voiced concern that fluoroquinolones may be over-prescribed and not always the appropriate choice. However, there are some factors that make it more likely for prescribers to choose fluoroquinolones – and patients saying that they are allergic to other antibiotics is an important one. Unfortunately, patients who believe they are allergic to other antibiotics often are not, and instead have experienced side effects of the medication that are normal, albeit unpleasant, such as an upset stomach. Determining whether a patient is truly allergic to other antibiotics can be a difficult and time-consuming task for healthcare providers, which makes fluoroquinolones seem like an attractive option for these patients. Another key reason for prescribing fluoroquinolones is the awareness of how effective they are in treating a wide variety of bacterial infections and uncertainty about whether the infection they are treating is resistant to other antibiotics. Along the same lines, fluoroquinolones are also chosen when other treatment options have already been tried. Healthcare providers may also opt for fluoroquinolones if they are concerned that a patient may not be able to successfully take an antibiotic that requires a more demanding schedule (that needs to be taken more often each day and for a longer period of time). What do the findings of the CADTH review mean for patients, their healthcare providers and the Canadian health system? As a patient, it’s important to be aware of the risks and benefits of tak-
ing fluoroquinolones if you have an infection and to discuss these with your healthcare provider. Knowing the difference between side effects and a true allergy to a particular antibiotic is important and can help ensure you’re receiving the antibiotic prescription that is best for you. Ask your healthcare provider for more information on this important issue. If you are taking a fluoroquinolone and experience any side effects, or if you have taken fluoroquinolones in the past and think you may be experiencing any long-term side effects of the medication, let your healthcare provider know. Knowing the factors that may influence fluoroquinolone prescribing can help healthcare providers and the healthcare system address them. Health Canada has already reviewed the safety of fluoroquinolones, and is now recommending that the safety information for all fluoroquinolone products be updated and is working with manufacturers to do so. Evidence shows that policy changes, tailored education, and sharing information can all be effective in positively influencing antibiotic prescribing. Strategies to increase awareness of local antibiotic resistance patterns and of local, national, and international clinical practice guidelines may also help support optimal prescribing decisions. Fluoroquinolones remain an important option for effectively treating some bacterial infections. But taking into consideration all of the important information and evidence before prescribing them will help ensure that we maximize the benefits of this medication while minimizing the risks. For more information on CADTH and the review of FQ prescribing, visit www.cadth.ca, follow us on Twitter @CADTH_ACMTS, or contact a H CADTH Liaison Officer in your region. n
Michael Raj, BSc MHA is a consultant for CADTH’s Knowledge Mobilization and Liaison Program, and Dr. Janice Mann BSc MD is a Knowledge Mobilization Officer at CADTH 26 Hospital News SEPTEMBER 2017
Improving healthcare for prisoners reduces emergency use By Bridget Newson court house may not be the first location that comes to mind when you think of healthcare. But the Toronto Police Service is responsible for making sure the healthcare needs of prisoners awaiting trial are met, wherever they are. A newly-published study in The Journal of Correctional Health Care demonstrates the effectiveness of an innovative new process for managing the diabetic needs of prisoners during court dates that eliminates acute diabetic events and a reliance on Emergency Medical Services (EMS) and Emergency Departments (ED). When Toronto Police Serviceâ€™s Court Services wanted to improve continuity and quality of care during transfers of prisoners with diabetes from their de-
tention centre to provincial court, it engaged Toronto Central LHIN (formerly the Toronto Central Community Care Access Centre). A scientific investigation was set up involving prisoners transported from the Toronto South Detention Centre for their court dates at College Park Court House. Previously, prisoners who experienced a diabetic event while at the court house were transported under police escort via EMS to a local Emergency Department for care. This resulted in significant costs to the healthcare system, as well as police and corrections services. The new process in the study, authored by Tim Pauley, Joy Matienzo, and Josie Barbita of Toronto Central LHIN and Joseph Ventura of Toron-
to Police Service, brings a community nurse to the courthouse for diabetic management and treatment of prisoners requiring care. Toronto Centre LHIN worked with home care service provider, Spectrum Health Care, who provided registered nurses. The process involves a registered nurse (RN) at the detention centre notifying Spectrum when a diabetic prisoner will be attending court. A community RN attends court shortly before the lunch break to assess the patient, monitor blood glucose levels and, if needed, give an insulin injection. This preventive approach was successful in completely eliminating all ED visits during the 72 court dates that occurred during the study period, and reduced healthcare and court services,
Bridget Newson is a Senior Communications Advisor at Toronto Central Local Health Integration Network
resulting in an 80 per cent reduction in per prisoner cost of administering care, from $797.58 to $161.93. There was a 57 per cent reduction in the per prisoner time required to provide diabetic care from over seven-hours per prisoner-time to just over three-hours. Since the initial study, the new process has been implemented at two additional detention centres. This new process has successfully eliminated Emergency Department visits and has resulted in an estimated systems-level cost saving exceeding $300,000 and expected to grow. This is an example of Toronto Central LHINâ€™s leadership in innovation in practice change and cross-sector collaboration to improve quality of H care and systems-level cost-savings. n
Analytics in medicine Using patient data to reduce ED wait times and leverage other levels of care By Tara Myshrall anadian healthcare organizations are continually pressured to provide quality patient care in the face of skyrocketing costs and rising patient loads, both of which weigh heavily on medical staff. While Ontario healthcare workers serve and save countless patients, hospitals and alternative levels of care (ALC) facilities struggle to keep up with the demands of a growing and aging population, along with ongoing fiscal restrictions. According to a recent article in the Toronto Sun, the largest and arguably wealthiest province in the country has the fewest hospital beds and nurses per capita, spends $1 billion of its home care budget on administration, and is plagued by long wait times, especially for specialist services. “Unless the federal government coughs up more cash than it’s currently offering, it’s going to get worse,” the article summed up. But while Ontario’s health system waits for an infusion of funding from the government, some healthcare institutions are taking matters into their own hands by using analytics to both control costs and improve patient care. Consider Toronto-based Markham Stouffville Hospital (MSH), which has achieved a 23 per cent reduction in the Emergency Department (ED) patient length-ofstay metrics with the help of clinical analytics tools. According to Grace Auh, Manager of Decision Support and Health Information at MSH, more complete, timely, and accurate information is improving quality of care, and patient satisfaction and outcomes. Compliance reporting is also more efficient. Hospitals in Ontario and elsewhere can achieve these performance gains by figuring out how to turn large volumes of data into useful information to improve operational efficiencies,
some healthcare institutions are taking matters into their own hands by using analytics to both control costs and improve patient care ensure better patient experiences, and meet increasingly onerous regulatory reporting requirements. The starting point is to establish a centralized analytic and data integration platform that can automate the processing of patient data, transforming it into insights that help these institutions drive systematic improvements. For example, MSH created an integrated ED performance portal that tracks eight key metrics fundamental to ED operations. Physicians and clinical staff can easily track metrics related to clinical outcomes, ED activities, physician performance, human resources, and key operational information. As Ontario’s population grows and ages, the pressure on EDs will likely continue, and even intensify. While not jeopardizing good patient care, hospitals strive to be in the 90th percentile for the lowest length of patient stay. But they face major issues, such as delays in discharging patients or moving them into long-term care. Bed shortages in the main hospital can increase wait times and cause ED bottlenecks. Analytics can play a vital role in offering hospital personnel a consolidated view of operations and ensuring integrated patient care. MSH, for example, has an automatic notification system that alerts internal staff when a long-term care home resident is admitted. The system sends notifications at each step of the patient’s experience, from arrival in the ED, admission to an inpatient bed, transfer to another unit, and discharge to
ALC. Internal teams use this information as they liaise with the staff at long-term care facilities to ensure a safe and timely discharge, as well as to minimize unnecessary transfers back to the hospital’s ED. Analytic dashboards allow personnel to monitor wait times, length of stay, and readmissions for specific diagnoses or procedures, with detail down to the physician and patient levels. Case costing is another area where hospitals can effectively use analytics to identify readmission rates and minimize potential inefficiencies, such as longer length of stays that drive up costs, or procedures where the costs exceed the funding granted by the Ontario Ministry of Health and Long-Term Care (MOHLTC). The demand for reporting to various regulatory bodies and funding sources brings additional administrative burdens. The Canadian Institute of Health Information, for example, requires data collection for certain types of patients such as those visiting the ED or coming in for day surgery. Hospitals must provide related activity reports on a weekly, monthly, or quarterly basis. The recent merging of 54 Community Care Access Centres (CCACs) under 14 Local Health Integrated Networks (LHINs) was part of a sustained effort to better manage funds and patient care for long-term care. However, legislation requires LHINs to provide the minister with annual reports, including audited financial statements, and hospitals have to meet these compliance require-
ments. Meanwhile, funding-based programs, such as the Ontario MOHLTC, Health Based Allocation Model (HBAM), and the Quality Based Procedures (QBP) also monitor key operating metrics and how hospitals perform in them. Unfortunately, in many hospitals, data resides in diverse operational systems, making it difficult to comply with these regulatory reporting needs. Thus a complete analytics and reporting platform should include data management technology that can enforce data quality and unify data to accelerate the speed at which stakeholders can retrieve it. The goal is to empower hospital personnel to spend less time collecting and consolidating information and more time analyzing it. At MSH, data resided in various operational systems such as Meditech clinical and financial systems, a Med2020 coding and abstracting system, a MedAssets case costing application, TREAT assessment databases, and other sources. It all had to be manually extracted and linked to create comprehensive reports. MSH dynamically linked these various databases using patient account numbers. Now users can instantly view high-level summary data, and drill down to more granular information when needed, which has reduced the submission timelines for key ministry compliance reports. All hospitals wrestle with these data management and reporting challenges on some level. They all want to improve clinical care and patient satisfaction, comply with government reporting requirements, and streamline decision making. Analytics technology can play a vital role in helping these hospitals succeed as they absorb a massive amount of data that is critical to managing stellar paH tient experiences. n
Tara Myshrall is an account executive at Information Builders, Information Builders helps healthcare provider and payer organizations to acquire, manage, and analyze their information more effectively using business intelligence, analytics, data integration, data quality, and master data management technologies 28 Hospital News SEPTEMBER 2017
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30 Hospital News SEPTEMBER 2017
By Naveed Nazir
ospitals are one of the toughest environments to work in, dealing with sickness and crisis daily. The pressure is high in the hospital intensive care units and the emergency departments, where speed and time are crucial and there’s very little room for errors, which can prove fatal. The battery of equipment in a modern ICU, including but not limited to the life support systems, generate voluminous streams of data. The Intensivists continuously monitor data to accurately follow patient status and their response to treatments. The information overload in the ICU contributes to the increased medical risks for patients. Hospital staff are human too, and mistakes do happen; studies have shown that a third of hospital staff may experience burn-out symptoms. The critical care physicians and researchers at Mayo Clinic in Rochester Minnesota set out to develop technology for synthesizing data into clinically relevant information at the point of care. By facilitating quick access to patients’ information through actionable dashboards, they published their work demonstrating reduction in the likelihood of errors in the ICU and the emergency departments. Their patent protected technology is licensed to a Mayo Clinic start-up company Ambient Clinical Analytics. Ambient Clinical further developed the technology into a US FDA 510K cleared product, AWARE™, which has been successfully deployed in several Mayo Clinic affiliated hospitals. AWARE™ is now available in Canada through Klinical Systems. AWARE™ is an add-on to most hospital EMR systems. AWARE™ aids timely delivery of evidence based interventions that help lower the cost of care and minimize the likelihood of
errors by continuously synthesizing the massive amounts of patients’ data. The Dashboards keep the entire care team on the same page, and intelligently alert relevant clinicians with the pertinent needs of each patient. AWARE™ dashboards organize patient data by organs and physiological systems using best care practices for improved clinical outcomes. The multi-patient viewer reduces time spent looking for relevant information in the ICU and helps eliminate redundancies in the overall care delivery. Pertinent information about the urgent needs of a patient is gleaned from a quick look at the patient thumbnail. The full single patient view is accessible from its thumbnail. The holistic view of patient’s multiple organ systems’ status enables the care team to organize timely delivery of evidence-based interventions. The functionality of Sepsis DART® – the Sepsis Detection and Response Tool is embedded in AWARE™. Studies have confirmed that mortality from Sepsis is reduced by over 50 per cent when the early detection is combined with aggressive response management. Sepsis DART® improves patient outcomes and quality of care during the hospital stays. The Mayo Clinic YES Board® is a multi-patient dashboard for real time situational awareness in the Emergency Department that improves patient flow and facility efficiency. The big-picture view of patient flow is continuously updated with patient health status and care team warnings. Elimination of information barriers enable faster care delivery resulting in higher provider and patient satisfaction, decreased wait times for lower costs. The optional RFID capability is available for AWARE™ and Mayo Clinic YES Board® that enhances
Naveed Nazir scouts for innovative healthcare technologies in his role as the CEO of klinicalsystems.com There is a special limited time opportunity to get Sepsis DART® Free by subscribing to Mayo Clinic YES Board® service by October 31st, 2017 www.hospitalnews.com
PRODUCT spotlight Continued from page 25
From the CEO’s desk
real time visibility into patient, staff and equipment location. The low-cost RFID embedded in the patient wrist tags enable tracing patients while they are in their room, corridor or restroom. The staff badges help determine who is in the room with the patient and how much care-time a patient is receiving. The medical staff will never again experience information overload or frustration when the ICU or ED gets hectic, rather, they will always see
what they need to see at the point of care, organized in the way they think. Their productivity is further enhanced by the built-in reporting infrastructure for external compliance and reflected in improved quality indicators. The “Replay” features enhance their ability to do process reviews and support the Six Sigma initiatives. Bottom Line: These solutions save time spent on data/information retrieval and reviews – increasing your H staff availability for patient care. n
This process removes the onus from the sending hospital to arrange patient transportation. CritiCall coordinates transport with Ornge or the appropriate Central Ambulance Communications Centre (CACC), monitors ETAs and confirms arrival time at the receiving facility. This aligns with Ornge’s goal of streamlining inter-facility patient transportation. Though there’s more to be done, the foregoing represents a significant improvement. As part of Ornge’s Strategic Plan 2017-2020, we will be introducing an online portal for hospitals to check the status of flights (approximate aircraft ETA, etc.) for same-day urgent and emergency patients, and to electronically book next-day non-urgent patient transports. The portal will improve effi-
ciency for hospital staff, as no phone call to our Operations Control Centre will be needed to book a non-urgent transport. Ornge is also working with Paramedic Services and CACCs in northern Ontario on a project to speed air ambulance response for time-sensitive cardiac, trauma and stroke patients. We are working toward direct transportation to regionally-based definitive care for time-sensitive clinical presentations, aimed at improving outcomes. These and other system improvements are directly related to the feedback we hear from stakeholders. We greatly value this information. We at Ornge know how important our service is to hospitals and patients and are committed to using feedback to continH ually improve our service to patients. n
Dr. Andrew McCallum is President and CEO of Ornge Continued from page 16
Are we ready yet? Preparing for disasters is a daunting task. Topics to cover can include risk and hazard vulnerability analysis: general readiness assessment and mitigation: incident management systems and communication: triage: hospital emergency surge capacity: integration of volunteers into the disaster response: caring for populations at-risk (specifically paediatrics, geriatrics and mental health): integrating hospital response with pre-hospital care and external support (such as disaster medical assistance teams): and medico-legal issues. We can draw some comfort from the fact that much of this material already exists in the literature and that Canada has experts who can deliver education and assessment on these topics.
It’s incumbent on hospitals to take the initiative on disaster preparedness, as this issue falls between the cracks of the healthcare and public safety systems. It lacks clear ownership and is often forgotten or deferred in the presence of more visible and pressing topics, such as hospital overcrowding and budget crunches. The first two steps are for hospitals to perform formal risk and readiness assessments. Once these are completed, the task of remedying identified gaps, planning for the high-impact or high-probability risks, and conducting drills will be far more manageable. Until these assessments are undertaken, plans developed and exercises practiced, we are all at risk of being found unprepared when the disaster – whatH ever it may be – strikes. n
Dr. Daniel Kollek is an Emergency Physician, Director of the Centre For Excellence in Emergency Preparedness and Associate Professor at McMaster University in Hamilton Ontario. Dr. Carl Jarvis is an emergency physician in Halifax NS, and is the medical director for emergency preparedness at EHS (the provincial EMS system). Further information on the Centre for Excellence in Emergency Preparedness can be obtained at www.ceep.ca or by contacting email@example.com www.hospitalnews.com
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