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Volume 22, Issue VIII CPC# 40065412

Hospital2009 News, September 2007 August

Emergency Services/Critical Care/ Trauma/Emergency Preparedness: Emergency & trauma delivery systems & emergency preparedness issues facing hospitals. Advances in critical care medicine. Emergency preparedness: Plane crash emergency exercise 8

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The anatomy of an emergency room move: Scarborough hospital opens new ER

Canada’s Health-Care Newspaper

Propelling lives through innovations in medical tranpsort

Inside • Editorial��������������������4 • Evidence Matters����19 • CEO Column�����������20 • Financial Health Matters��������������������21 • Patient Safety����������26 • Careers��������������������31

More Features • Pediatric Critical Care Response Teams: Prevention at its best • Mask fit testing important part of pandemic planning • CritiCall Ontario answers the call for critical care support

Every year Ornge transports more than 18,000 patients, responding to calls everywhere from urban centres to the remotest reaches of northern Ontario. By Lori McLeod

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hree years ago a sunny spring day turned tragic when a terrible accident left an Ottawa-area toddler clinging to life by a thread. Then just 18-months old, Caylen Laberge suffered catastrophic injuries after being run

over by a lawn mower. “My first thought was, he doesn’t have a face,” Marcie Beaudoin, critical care flight paramedic (CCP) with Ontario transport medicine service provider Ornge, says of her first look at the toddler’s injuries. Ms. Beaudoin and fellow CCP Patrick Auger

were on duty when the Ornge Communications Centre, located near Toronto’s Pearson Airport, received the call to airlift Caylen. His injuries were the worst case of trauma the rural hospital that first admitted him had ever seen, and a helicopter was required immediately to take him to a

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facility with more specialized care. What followed is an amazing story of human resilience, compassion and ingenuity. Saving Caylen would draw on the little boy’s remarkable will to live, and require the existence of an incredible development in modern patient

care – transport medicine. The concept is simple to understand, but complex to execute. It involves the provision of sophisticated care for critically ill and injured patients, at the same time they are being transported to or between medical facilities. In the vast province of Ontario, which has a total area of more than 1-million square kilometers, the Ornge transport medicine service was founded in 2006. Named for the distinctive colour of its helicopters, airplanes and land vehicles, Ornge’s roots go back to 1977. It was then the fledgling idea of medical transport began in the province, through the inaugural flight of a single helicopter more than thirty years ago. “The service has developed dramatically in subsequent Continues on page 13

Work in an environment where excellence and innovation in practice, education, informatics and research are valued. Promote and restore optimal health and assist children and families to effectively adjust to health challenges. Provide care that recognizes and respects the diversity of the community you serve and the uniqueness of each child and family.

We are currently accepting resumes for nursing positions in all Paediatric specialty units, as well as experienced Physiotherapists. For a complete listing, visit www.sickkids.ca.

If you share our commitment to kids and to your career, please forward your resume, in confidence to hr.recruiter@sickkids.ca. www.sickkids.ca


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McMaster Children’s Hospital opens regions first dedicated child & youth mental health unit By Kim Sopko

izing with friends.” Since his diagnosis, Shane has been undergoing a variety of treatments and therapies for his disorder at McMaster Children’s Hospital and has become a success story for the Child and Youth Mental Health Program. “My tics and compulsions no longer define me. I’ve learned how to control my OCD rather than letting it control me,” Shane says proudly.

On June 8, 2009, Shane joined the Minister of Health and Long-Term Care, the Honourable David Caplan, and Hamilton Health Sciences staff to cut the ribbon at the official grand opening of the new Royal Bank of Canada (RBC) Child and Youth Mental Health Unit at McMaster Children’s Hospital. The opening of this unit marks a first for the region and is one of the largest of its kind in Canada. The unit houses 22 inpatient beds, as well as specialized day hospital and outreach services for children and youth up to age 18. The unit has the capacity to care for six pediatric and 16 youths at one time and it is anticipated that as many as 450 children and youth will receive care in the unit each year. Children and youth living throughout the Hamilton Niagara Haldimand Brant, and Waterloo Wellington Local Health Integration Networks can be referred to the program, which employs a very diverse and talented team of interdisci-

plinary health-care professionals that includes psychologists, psychiatrists, nurses, child and youth workers, dietitians, social workers, pharmacists, and occupational therapists. Currently, one in five children are living with mental illness and of those children only one out of five receives the care they need. “There is a critical need for increased child and youth mental health services in Canada and this is a significant gap that we cannot afford to ignore,” says Murray Martin, President & CEO of Hamilton Health Sciences. “I would like to thank Minister Caplan and the provincial government for investing in this much-needed program, as well as express our appreciation to RBC for their contribution. As we open this new unit, I am confident that we are taking steps in the right direction to meet the needs of youth in our region and beyond.”

retain the ones we currently have. Recruitment is very competitive and we need to keep our physicians happy.”  The first unofficial Doctors’ Day was celebrated in North America on March 30, 1933. Inspired by the story of Dr. Crawford Long who removed a neck tumour for a patient in Jackson County using anaesthesia for the first time, Doctors’Day was instituted on the anniversary of his accomplishment. Cards were sent to physicians and their wives, flowers were left on the graves of deceased doctors and a formal dinner was held.  At York Central, things were celebrated a bit differently but with the same acknowledgement for physicians. “It was better than I had

expected,” says Webster. “A large part of our medical staff came out as well as members of Administration and Nursing Staff.  We started the day with a gourmet breakfast followed by a lecture by Dr. Mamta Gautum from Ottawa.”  In 1990, legislation was passed by the House and Senate to establish a national Doctors’ Day in the U.S. Webster only hopes that Canada will follow suit. “There is a Nursing Week, a Secretaries Day, a Physiotherapy month, why not a Doctors’ Day?” says Webster.  And, it’s important for the general population to show they recognize and appreciate physicians. “If this was done on a provincial level it would encourage communities to schedule events that would

focus on education,” says Dr. Larry Grossman, Chief of Staff at York Central Hospital. “Ultimately the community at large will benefit by developing better relationships with physicians.”  Since the first use of anaesthesia, health-care officials have never stopped in their attempts to minister to the sick and alleviate human suffering. What better way to honour these contributions than with an annual Doctors’ Appreciation Day.  “At York Central, there were many who simply wished the doctors a “Happy Doctors’ Day!” says Webster. An act that is simple enough and long overdue.   Maria Cortellucci is a freelance writer in Toronto.

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dolescence. It’s a time when most youth are preoccupied with their social lives, dating, pop culture and just trying to fit in. These are the years when emotions run high, everything seems bigger, more important, and oftentimes harder to handle. Being a teenager is tough, especially for Shane Murphy, who at the age of 13 was diagnosed with Severe Extreme Obsessive Compulsive Disorder (OCD) and Tourette Syndrome. “I always knew I was different from most kids. It was difficult starting high school because I felt estranged from others, always feeling that I could not fit in because of my tics and compulsions. I shook my head constantly and my legs would shake uncontrollably,” says Shane, who is now 15. “I was sometimes made fun of when my compulsions became visible to others. I would be walking down the hallway at my high school and I would have to step in the middle of

On June 8, 2009, McMaster Children’s Hospital’s new Child and Youth Mental Health Unit was officially opened – a first in the region.

every tile on the floor because I didn’t want to risk touching the edges, kind of like in the game ‘Operation’. My mind was constantly full of OCD thoughts making me count and recount all the panels on the ceiling, or walk a certain way, or forcing me to recheck all the locks and doors before going to bed. It was difficult to find time to focus on anything else, like homework or music or social-

Doctors’ Day By Maria Cortellucci   n June 12, York Central Hospital in Richmond Hill, Ontario celebrated the contributions of its 358 physicians by organizing and instituting an official Doctors’ Appreciation Day. “I believe that doctors as community leaders are often viewed as elite and distant,” says Brenda Hogg, Deputy Mayor of Richmond Hill, who attended the ceremony to designate Doctors’ Day on behalf of the town council. “Doctors’ Day brings them into the public realm to be celebrated but also to be recognized as

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an integral part of our human community.”  After visiting hospitals in the U.S. over a year ago, York Central’s Director of Medical Affairs Arlene Webster was first introduced to the idea of Doctors’ Day. She returned to the hospital, inspired with a mission. “Doctors are the foundation of our hospital and without them we can’t do what we do best: Caring to make a difference,” says Webster.  Webster believed that the hospital could benefit from Doctors’ Day in a number of ways. “It’s a great way to recruit new physicians and

Kim Sopko works in Public Relations & Communications at Hamilton Health Sciences.


Hospital News, August 2009

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Employees on leave for mental illness return to work sooner when family doctor works with mental health professional

Individuals who are on short-term disability leave due to mental illness may return to work sooner when their family doctor actively partners with a psychiatrist or other mental health professional, according to a new study from the Centre for Addiction and Mental Health (CAMH). When family physicians work collaboratively with specialists, the result seems to benefit both the employee and the employer, says study author Dr. Carolyn Dewa, Program Head for the Work and Well-being Research and Evaluation Program at CAMH. Individuals on shortterm disability are more likely to avoid transitioning to longterm disability, and to have a shorter disability leave, while employers see a cost savings in disability payments. Estimates show that about ten per cent of the working population is diagnosed with depression, anxiety, or other mental illness each year. In Canada, this represents about $17 billion in productivity losses to the economy. Eighty-five per cent of participants treated in a collaborative-care team were able to return to work, compared to 63 per cent who received standard care. Just 7 per cent of those receiving collaborative care transitioned to long-term disability, compared to 31 per cent treated by family physicians alone.

Study reveals that infants with fever are treated differently in emergency departments

Differences in testing and treating infants with fever were highlighted in a study published in the August issue of Pediatrics. This is the first multi-centre study that looked at how infants with fever are diagnosed and treated in emergency departments across Canada. “Fever in infants under three months of age is common, but it could be a sign of serious bacterial infections, so infants need to be treated immediately,” says Dr. Ran Goldman, Medical Director of the Emergency Department

In Brief

at BC Children’s Hospital, an agency of the Provincial Health Services Authority. Dr. Goldman is also Senior Associate Clinician Scientist, Child & Family Research Institute and Associate Professor, Department of Pediatrics, University of British Columbia. “We found that infants with fever were receiving good care, but pediatric emergency departments in six centres were diagnosing and treating these infants differently.” The study was led by Dr. Goldman while he was at the Hospital for Sick Children in Toronto and was done for Pediatric Emergency Research of Canada. The research team looked at 257 infants in six pediatric emergency departments across Canada. Blood and urine tests were ordered in the majority, but the rates of lumbar puncture, respiratory virus testing, and chest x-rays were different across centres. In addition, 55 per cent of infants received antibiotics, with significant differences in the numbers and types of antibiotics. “We want to give babies the best care possible,” says Dr. Goldman. “At the same time, we don’t want to expose them to unnecessary risk, so if a test isn’t needed, we shouldn’t administer it. Similarly, if we’re not doing enough, we need to determine what else is needed.” Dr. Goldman says what is needed next is further research into why there are differences in treatment, consensus across pediatric centres, and the development of national guidelines.

Canadians spending less on prescription drugs during recession

Prescription drug sales, long thought to be ‘recessionproof,’ have taken a hit in the current financial downturn, a new report from Brogan Inc. finds. The report, “From Wall Street to the Pill Cabinet,” looked at public and private sector spending on prescription drugs across Canada to see if the recession had an impact on purchasing what many consider to be essential medicines. “There has been a rapid drop in prescription drug sales growth over the past two quarters leading into the recession,” says Richard Lavoie, Senior

Economist and Director of Health Intelligence at Brogan. Most severely hit were the private sector in Ontario and the Prairie provinces and the public sector in British Columbia. Anti-thrombotic drugs, used to reduce blood clotting and platelet formation, experienced the most significant reduction in spending. “The relationship between slowing private sector drug sales and the employment situation is unclear,” says Lavoie. “Although the number of drug plan beneficiaries hasn’t dropped they may be cutting their drug consumption,” he continues. This may be a psychological response to the recession, speaking to anxiety over worsening economic times, rather than absolute job losses.

Canada’s pathologists unveil new measures to improve patient care

The Canadian Association of Pathologists (CAP) wrapped up its 60th annual meeting last month by introducing three measures to ensure that patients receive the best possible health care. These recommendations on testing standards, workload and cancer protocols stem from a five-point plan of action that CAP announced in 2008. CAP’s first set of recommendations concern test quality assurance in the area of clinical immunohistochemistry (IHC). IHC tests are used to determine if cancer is present and to identify appropriate treatment. “We have been calling for this initiative for some time now. We must now all join efforts on a national initiative to standardize the IHC testing process, develop recognized educational activities for technologists and pathologists, and implement recommendations for best practices in both, internal and external quality assurance programs,” says Dr. Emina Torlakovic, Chair of CAP’s National Standards Committee for IHC. “This will help ensure that Canadian patients receive safe, timely and equitable care.” CAP’s second report contains guidelines to adequately measure the appropriateness of a pathologist’s workload. These recommendations will facilitate planning, ensure reasonable task distribution across departments, and provide benchmarks for what is a prac-

tical and safe workload. CAP has also formally endorsed the Cancer Protocols developed by the College of American Pathologists in collaboration with a broad range of medical professionals and institutions. These protocols will assist pathologists in providing uniform relevant information when reporting results of surgical specimen examinations. They also allow these results to be vetted by a larger population.

Canada joins international effort to provide access to health research

Accelerating the development of discoveries and innovations and facilitating their adoption through free and open access to research findings. This is the aim of an important new initiative that will provide researchers and knowledge users free access to a vast digital archive of published health research at their desktop and connect them to an emerging international network of digital archives anchored in the United States. The Canadian Institutes of Health Research (CIHR), the National Research Council’s Canada Institute for Scientific and Technical Information (NRC-CISTI), and the US National Library of Medicine (NLM) have announced a three-way partnership to establish PubMed Central Canada (PMC Canada). PMC Canada will be a national digital repository of peer-reviewed health and life sciences literature, including research resulting from CIHR funding. This searchable Web-based repository will be permanent, stable and freely accessible. The initial release of PMC Canada, to be available in fall 2009, will include a basic bilingual interface, a manuscript submission system for CIHR researchers and a bilingual help desk. An advisory committee of Canadian health researchers and other stakeholders will guide PMC Canada’s future development.

All Ontario hospitals now filmless; another step towards comprehensive ehealth system achieved For the first time in Ontario’s history, all 148 hos-

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pitals are now able to produce and share filmless diagnostic images including x-rays, CT scans and MRIs within their facilities using picture archiving and communications technology. West Haldimand General Hospital marked a digital milestone by shutting down its x-ray film system and turning on its new digital imaging system. It was the final hospital of 148 hospitals to become technology enabled. The initiative is an integral part of Ontario’s ehealth strategy. “This is a significant milestone for the way patient care is delivered in the province of Ontario,” said David Caplan, Minister of Health and LongTerm Care. “When providers can access images in a digital way, patients can continue to receive care close to home and will spend less time waiting for their results.” As a result of this announcement, 12 million digital images, produced annually in Ontario hospitals, will now be stored electronically instead of needing to be printed out and kept in a patient’s file. In addition, patients will spend less time waiting between patient visits and results. In what previously took 48 to 60 hours, a radiologist in any location can now access, read and report on a digital image in just one hour or less.

Telehealth model cuts re-admission for heart failure by 54%

A Canadian one-of-a-kind home telehealth monitoring program developed by the University of Ottawa Heart Institute(UOHI) has cut hospital readmission by 54% for heart failure patients. The program has also been shown to save up to $20,000 for each patient safely diverted from an Emergency Department visit, re-admission and hospital stay. More than 500 heart failure patients have been followed by the HeartInstitute since 2005. Each day, patients measure and send their vitals signs from weight to heart rate and medication side effects - to the Heart Institute. The Institute also employs an automated calling system that reaches out to patients for surgical follow up, heart failure and coronary conditions ranging from chest pain to heart attack.


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Time to put pandemic plans into action and share best practices

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he timing of this month’s focus on emergency preparedness/ pandemic planning is impeccable as the world faces the first pandemic in over 40 years. While running the risk of being repetitive, having addressed the H1N1 virus in this column in May, much has happened since then and it’s a topic worthy of conversation - again. On June 11th the World Health Organization (WHO) raised the H1N1 threat to Phase 6 – and declared a pandemic. With over 30,000 confirmed cases in 74 countires, Dr. Margaret Chan, DirectorGeneral of the WHO stated that, “We are in the earliest days of a pandemic.” As of July 6th there were 94.512 laboratory confirmed cases world-wide, and just over 400 deaths. At home here in Canada, the latest numbers (as of July 15th) confirmed 10,156 cases as reported by the Public Health Agency of Canada (PHAC). The WHO has said the H1N1 virus is the fastest moving pandemic ever, spreading as much in six weeks as past pandemic flus spread in six months. For this reason, reporting of individual confirmed cases is no longer required. Authorities must now report only clusters of severe cases

and deaths. We have been warned about an impending pandemic for at least a decade. Until now, nothing has happened, and now that it has, I have to wonder: Are our hospitals equipped to deal with it? The fable of the boy who cried wolf comes to mind. Have repeated warnings of imminent pandemics that never came to fruition made us complacent in the face of this very real threat? Are we taking this virus seriously enough? I also can’t help but wonder if its low level of severity (in most cases) is giving us a false sense of security. While I can only speak for myself, I haven’t taken any precautions. I still see people who are sick going to work and out and about so I think it’s fair to assume, a lot of us aren’t taking this seriously. Perhaps the first Tamiflu resistant case found in Quebec, and this patient’s real-life account of his battle against the virus will serve as a wake-up call. The Conference Board of Canada’s report Ready or Not: Effective Pandemic Response (July 2009) highlights that this pandemic is not at all what was expected. The SARS outbreak in Toronto and Vancouver brought emergency preparedness and pandemic planning to the forefront. Many organiza-

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tions (and most hospitals) dusted off their pandemic plans and put a great deal of resources into emergency preparedness. The report points out that “For all the planning and preparation that has occurred, the H1N1 pandemic is looking and behaving much differently than expected.” In fact, many organizations involved with the report even shared that they never expected a pandemic to actually occur. Unfortunately it has, and it appears to have caught many off-guard for several reasons. The report highlights several reasons we have been caught off-guard by H1N1: We expected the next pandemic to be a form of avian influenza; it’s rapid spread and becoming a full-blown pandemic in a matter of weeks; it’s not demonstrating the usually wave-like characteristics that most other flu viruses do, with the summer months seeing a decline in new cases and; it’s low level of severity. Many of the pandemic plans organizations have established do not apply as well to H1N1 because of all these ‘surprises”. So are we ready? Most importantly, are our health-care professionals and hospitals ready? It’s hard to imagine how an already under-funded healthcare system will handle it. Staff and resource shortages are going to be felt more than they are currently and if this virus mutates and does become more severe and deadly – what then? Only time will tell. If you’re hospital has implemented innovative ways to prepare or manage this pandemic, we want to hear about them. Have you stepped-up hand-washing campaigns or found effective ways of communicating updates on the virus with your staff? Have you started outreach in your community to help prevent the spread of the virus? Is your hospital ready for what could prove to be the worst flu season in 40 years? Please share your stories with us. We’re all in this together and over the next few months Hospital News can serve as a forum for hospitals to share best practices in dealing with this pandemic. Kristie Jones Editor Hospital News editor@hospitalnews.com


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Study finds new way to treat heart attacks that reduces risk of life-threatening complications By Tammy La Rue

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ransferring heart attack patients to specialized hospitals to undergo angioplasty within six hours after receiving clot-busting drugs reduces the risk of lifethreatening complications, according to a Canadian-led study published last month. The findings, published in the New England Journal of Medicine, suggest that routine early transfer of patients after clot-busting drugs are administered results in significantly better outcomes than the current practice of transferring patients only when the clotbusting drugs fail. “The results of the study – the largest randomized trial of its kind – are dramatic,” says Dr. Warren Cantor, medical director of the interventional and invasive program at Southlake Regional Health Centre in Newmarket, who spearheaded the study with Dr. Shaun Goodman, associate head of cardiology at St. Michael’s Hospital in Toronto. Called the Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI), the study involved a large group of Canadian cardiologists, internists, emergency department physicians and paramedics. It was supported by the Canadian Institutes of Health Research and coordinated by the Canadian Heart Research Centre. The study followed 1,059 heart attack patients who were treated with clot-busting drugs at community hospital emergency departments in Ontario, Manitoba and Quebec. It compared a strategy of transferring heart attack patients to hospitals with on-site angioplasty facilities to undergo angioplasty within six hours after administration of clot-busting drugs, as opposed to the traditional approach of transferring only those patients when clot-busting drug treatments are unsuccessful. All patients in the study initially sought treatment at a hospital without angioplasty capability and were treated with tenecteplase, a newer clot-busting drug. Patients were then randomly assigned to one of two groups: urgent transfer for angioplasty within six hours, or standard care (no transfer for angioplasty within the first 24 hours unless the clot-busting medication failed to restore

blood flow in the blocked artery). Patients who received standard care often underwent angioplasty 1-3 days after the heart attack. Overall, 17 per cent of patients receiving standard care had serious cardiac complications within 30 days, compared with 11 per cent of those transferred immediately for angioplasty. That represents a 36 per cent reduction in potentially life-threatening complications, including repeat heart attacks, with no difference in major bleeding complications between the two groups. Angioplasty – which uses a combination of catheter-mounted balloons and stents to open a completely blocked coronary artery and restore blood flow

to the heart – is accepted by the medical community as the best initial treatment for heart attacks when performed within 90 minutes of arrival at a hospital. “The challenge, though, is that this is a goal that few hospitals in the world can achieve unless they have angioplasty facilities on site,” explains Dr. Cantor, adding that less than 25 per cent of hospitals in North America have these resources. Until now, physicians have been reluctant to transfer patients to another hospital to undergo angioplasty soon after administering clot-busting medication as a result of earlier studies that revealed excess bleeding and no benefit with this approach.

“This study confirms that patients who receive clot-busting drugs at hospitals without angioplasty facilities should be transferred to an angioplasty centre to undergo the procedure within six hours,” Dr. Cantor emphasizes. “Although many hospitals cannot transfer patients for angioplasty within 90 minutes of hospital arrival, stabilizing patients initially with clot-busting medications, followed by angioplasty within six hours, is highly practical and realistic in most parts of the world.” Dr. Cantor explained that Southlake Regional Health Centre has been incorporating this treatment strategy gradually into its practice over the last year, with positive results.

“Southlake has been bringing regional hospitals on board to rapidly transfer their heart attack patients to Southlake’s specialized cardiac centre to ensure that the patients have access to the best treatments regardless of where they live.” The hospitals currently involved in Southlake’s program include Royal Victoria Hospital in Barrie, Headwaters Health Care Centre in Orangeville, Collingwood General and Marine Hospital in Collingwood, Orillia Soldier’s Memorial Hospital in Orillia and Stevenson Memorial Hospital in Alliston. Tammy La Rue works in communications at Southlake Regional Hospital.

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Community stroke rehab team making house calls By Anne Kay

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he rehabilitation patients receive following strokes can greatly enhance their quality of life. The community stroke rehabilitation teams (CSRT) are the first interprofessional teams in Ontario dedicated to providing a range of rehabilitation services specifically for stroke survivors after they are discharged from hospital. The Thames Valley CSRT is one of three such teams in Southwestern Ontario. Whether the survivors are living in their home or in a nursing or retirement home, the team is there to help. Each team consists of a physiotherapist, occupational therapist, nurse, social worker, speech language pathologist, therapeutic recreation specialist and two rehabilitation therapists. The CSRT services complement community care access centre services by enhancing services in the home, and outpatient therapy programs by taking their expertise to stroke survivors in smaller communities and those unable to come to clinics. “Our goal is to provide stroke survivors with therapy that allows them to reconnect with what “living” means for each of them—be it gardening or meeting friends for morning coffee,” says Monique Crites, coordinator of the three CSRTs. “Recovery occurs rapidly for

Denis Turcotte, right, receives stroke therapy in his Tillsonburg home from physiotherapist Rob Fazakerley and clinical lead Martha Korzycki who are with the Thames Valley CSRT.

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the first three months after a stroke and continues beyond that time, but intensive and timely therapy is needed to maximize recovery.” For Fred Johnson* the CSRT team is helping him achieve his goal of riding his bike again. Fred, an active 69 year old who regularly rollerbladed and skied, awoke one morning in March with vertigo, hiccups and blurred vision. Once he arrived at the hospital, it was determined he had a stroke. When Fred returned home 15 days later he was using a walker and spending most of his day in bed. The CSRT team came to his home to help him with exercise routines to improve his balance, and three weeks later he began walking independently. The type of therapy interventions are tailored to each client’s needs and can last from two to 16 weeks. “The physiotherapist’s extensive experience resulted in well thought out exercise programs that are helping me regain my active lifestyle,” says Fred. “It’s great having the CSRT come to our home in Tillsonburg,” says Alrae Turcotte, whose husband Denis had a stroke. The team assessed Denis’ therapy needs, then worked with him to set treatment goals. “Stroke is the leading cause of adult disability, and the need for the CSRT program is great,”

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says Deb Willems, regional rehabilitation coordinator for the Southwestern Ontario Stroke Strategy. In the Thames Valley district (Middlesex, Oxford and Elgin counties) there were 1,205 patient visits to emergency and acute care admissions resulting from stroke in 2006/07. The Thames Valley CSRT began serving clients in February, and already they have 38 regular clients and 16 on the waiting list. “Even those with severe strokes are progressing well due to the intensity of therapy and supports for care givers,” says Monique. The team also speaks with community groups about ways to prevent and manage stroke, with a key role being to teach strategies to minimize the risks of a second stroke. The other two CSRTs serve clients in the Huron Perth and Grey Bruce areas. Referrals to the program are centralized at Parkwood Hospital, part of St. Joseph’s Health Care, London, and come from the Community Care Access Centre, hospitals, long-term care homes, doctors, family members and stroke survivors. CSRTs are funded by the South West Local Health Integration Network’s Aging at Home initiative. The teams are a collaborative partnership between St. Josephs Health Care, London, Huron Perth Healthcare Alliance, Grey Bruce Health Services, South West Community Care Access Centre, the Southwestern Ontario Stroke Strategy and primary care providers. Through specialized expertise, coordinated teamwork and a personalized approach the CSRT is helping stroke survivors truly experience life after stroke. Fred still needs help getting on and off his stationary exercise bike, but thanks to therapy from the CSRT is looking forward to resuming his 50 km bike ride next spring. Denis is exhilarated after therapy visits because of his achievements and optimistic about his recovery. His new found independence with an electric wheelchair is allowing him to take back control of his life. “The CSRT is professional and compassionate. Without them Denis wouldn’t be as far along, or as hopeful he can improve even further,” says Alrae. * Not his real name Anne Kay is a Communication Consultant at St. Joseph’s Health Care in London.


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Operations Centre should act as a clearing house through which nuclear medicine clinics can report the demand, supply and alternatives for their region, as well as their capacity to help other regions. A registry of patients requiring testing along with guidelines for prioritizing their need should be established. Most urgent is the need to recognize that for children diagnosed with cancer there is no alternative test. They must go to the front of the line in a system where testing with isotopes is being rationed. As hospitals adapt to providing costlier alternatives, and running longer hours, it must also be recognized that health care costs will rise. The federal government cannot stand idly by and allow our hospitals to be burdened with debt or forced to cut costs in other areas as they struggle to pay higher costs for scarce isotopes and for alternative procedures that cost a great deal more. Finally, we need to act on the Canadian Association of Nuclear Medicine and the American Academy of Medicine’s recommendation to strike an international panel to revisit the feasibility of commissioning the abandoned MAPLE reactors at Chalk River. These facilities safely and successfully proContinues on page 25

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n the wake of the latest shutdown of the nuclear medical reactor at Chalk River, near Ottawa, Canadians have learned two new words: ‘isotope’ and ‘PET scan.’ Before its latest shutdown in May, the Chalk River reactor produced 40 per cent of the global radioactive medical isotope supply, used in bone scans and many other heart and cancer diagnostic tests for 5000 Canadian patients every day. The federal government, who is responsible for the Chalk River reactor, still has no alternative plan in place, despite warning from experts following two previous unscheduled shutdowns. Without isotopes, these diagnostics tests cannot be performed. Without an accurate diagnosis, treatment is compromised. That’s why it’s not an exaggeration to call the isotope shortage a national health-care crisis. With no alternative plan in place, the federal government has placed thousands of Canadian patients undergoing testing and treatment at risk each day. The Conservative government has claimed that alternative medical tests can make up for dwindling isotope supplies, but these decades-old techniques are less effective, not widely available, more expensive, and dangerous for child patients. Thallium was abandoned years ago for heart stress testing because the Te99 gave better pictures. Take the example of PET scans. First of all, they take longer to administer. Where some clinics are able to do 40 or 50 bone scans in a regular working day with isotopes, PET scanners are able to perform a maximum of 12 scans per day. PET scanners are not readily available across Canada either, particularly in Atlantic Canada, Ontario, Saskatchewan and Newfoundland. Most alarmingly, PET scanning is also not an option for paediatric cancer testing, because the radiation is too strong for children. For our kids, isotopes are the only option. The Conservative government has failed to acknowledge the true impact of the shutdown at Chalk River and the gravity of this health- care crisis. Once

a world leader in isotope production, they have provided no assurances that any additional scarce and expensive foreignproduced isotopes will come to Canada. Cancer patients urgently require a plan to deal with the shortage and manage the demand for tests. Leadership is required to get us through this crisis – and soon. That’s why Liberals recommend the following actions be taken: The government having taken our advice and appointed an ‘Isotope Czar’ , must now ensure that Dr. McEwen works closely with the Canadian Nuclear Medical Association and be able to give transparent advice to the Minister. Canadians need to have confidence that the dwindling isotope supply is being wellmanaged while new solutions are being sought.

HAIR CARE, ORAL CARE, HOMECARE, LAUNDRY, BABY CARE

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By Dr. Carolyn Bennett

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Surviving the health-care crisis in cancer and cardiac testing

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Hospital News, August 2009

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Hospital News, August 2009

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Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

Emergency preparedness: Plane crash emergency exercise By Jennifer Laidlaw

P

rovidence Health Care (PHC) continues to lead the way in emergency preparation with its participation in a recent mock plane crash scenario. Emergency preparedness is at the forefront of PHC minds, not only because disasters like these are imminent, but because the 2010 Olympic Games are looming and with Vancouver’s St. Paul’s Hospital (SPH) being an official hospital venue, staff need to be well prepared for any kind of stress to services. Vancouver Fire and Rescue Services (VFRS) led the mock plane crash exercise, which involved 10 other agencies including SPH, E-COMM, Vancouver Police Department, BC Forest Services and the City of Vancouver. Casualties (actors covered in fake blood) were transported from the crash site at Brockton Oval in Stanley Park to a mock emergency room set up in the courtyard at St. Paul’s Hospital so as to not disturb the real emergency room services. Here, emergency staff determined the order and priority of emergency treatment based upon the special needs of each victim brought in from this mass-casualty setting. Jeanette Beattie, Leader, Emergency Preparedness Program at PHC, believes it’s important to educate staff through participation in drills and simulations, “Exercises are invaluable tools for identifying gaps, determining remedies and validating current processes.”

Triage nurses Glen Cardinal and Patti Nugent (orange vests), triage a “casualty” as a stricken “family member” adds emotional tension to the situation during a mock emergency preparedness exercise. Emergency nurses and physicians were able to use this as an opportunity to test and validate triage roles, to test the role of admitting clerks and to engage Access Services in identifying bed space at SPH as well as Mount Saint Joseph Hospital (MSJ). MSJ staff used this opportunity to discuss the “real time” situation at their hospital and what they would need to

do to accommodate patients from SPH if a real disaster were to occur. Two residential sites sent observers to participate in the exercise, providing a great opportunity for them to find out what goes on at acute sites during a code orange and how their sites could be of support. One participant on the triage team noted how quickly they were able to find their groove

during the simulation, and their triage response became more efficient as the exercise progressed. The no-fault environment allowing players to train and practice for real emergencies, in turn, decreases anxiety during real-life incidents. SPH staff observers were provided with clipboard, task sheet and a Disaster Observer Tag. Their role was to objec-

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tively observe a segment of the action (ie. Admitting clerks) and note the response and communication flow. Participants were provided with vests (reflecting Hospital Emergency Incident Command System positions), t-shirts or special tags depending on their role. PHC Media services and VFRS were both shooting footage of the disaster scenario to be used for future training. The exercise provided a valuable opportunity for agencies to work together and learn how to prepare, react and communicate in a disaster situation. Each agency has its own response system and when brought together, flawless communication amongst all parties is the key to a successful response. The scenario, which lasted four hours in total, was a great success and helped strengthen Providence Health Care as an organization. The next multi-agency, functional exercise will occur in November as Exercise Gold, in preparation for the Olympic Games. Between now and then, a variety of smaller exercises, drills and demonstrations will take place with acute sites focusing on radiation and decontamination and residential sites focusing on code green evacuation. Jennifer Laidlaw is a Communications Coordinator at Providence Health Care in Vancouver.


Hospital News, August 2009

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Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

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Nursing graduates being welcomed into intensive care unit By Michelle Tadique

S

t. Joseph’s Health Centre is opening the ICU doors to new nursing graduates interested in a unit that has traditionally been designated for the more seasoned and experienced nurse. With support from the Ministry’s New Graduate Guarantee program, Silvana Biscaro, Director for St. Joseph’s Emergency, Critical Care and Access Services portfolio is excited with the opportunity to provide new nursing grads with the training, orientation and support needed to transition into the critical care setting. “This new generation of nurses is looking for challenges and variety in their practice and they are attracted to the critical care environment. By offering them the right level of support, we are confident that they will become successful team members in the ICU,” says Biscaro. St. Joe’s recently participated in a research study with 15 acute care hospitals across the province that looked at the impacts of a bridging program for 4th year baccalaureate nursing students interested in entry-level employment in critical care. Conducted by the University of Western Ontario and the University of Ontario Institute of Technology, nursing students were split into two different groups to complete their 430-hour practicum. The intervention group participants were enrolled in Durham College’s Critical Care Certificate program and were partnered with a preceptor trained in critical care mentoring for their practicum. Students in the control group were paired with a preceptor who had completed a basic hospital-sponsored preceptor program for their placements. While the final and conclusive study results are still being complied, outcome measures did reveal that the students showed a significant rise in their comfort, confidence, and competence levels at the completion of the study compared to when they initially began their ICU placements. Students were also able to secure jobs in organizations of their choice. Results of the study may also inform policy, funding, and curriculum planning decisions with respect to specialty education in undergraduate nursing programs.

Molly Magee, a new grad nursing student who participated in the study was hired in St. Joe’s ICU. “I’ve always known that I wanted a nursing career in the ICU,” says Magee. “I think that it would have been more difficult for me to get a placement in the ICU if I didn’t participate in the (research) study, since it’s really hard for a new grad to do their placement in critical care,” she adds. The New Graduate Guarantee program also helped to secure her employment in the ICU and ensured that her introduction into the critical care setting was done with the guidance and support of her preceptor. Magee was also sent on the RN Exam Review course to assist her in preparing for her final nursing certification exam. Due to effective capacity planning, St. Joseph’s has been very successful in bridging 96 per cent of our new grads into full-time permanent positions throughout our five clinical program areas. To ensure their success, the Health Centre has a number of internal initiatives to help support new grads as they enter their practice starting with Interprofessional orientation – an approach that is unique to St. Joe’s. Through five core competen-

cies (trust and respect, knowledge of roles, appreciating differences and conflict resolution, sharing power and shareddecision making) new grads familiarize themselves with the other key health-care providers they will be working with on a daily basis such as social workers, respiratory therapists, occupational therapists, and pharmacists. “It takes us out of silos and sets the tone for a culture of collaboration, which is important,” says Elizabeth McLaney, Interprofessional Education Manager at St. Joseph’s. “The process brings diverse groups of people together in order for them to learn with, from and about each other, fostering teamwork that we ultimately hope will translate into the work at the bedside.” More specifically for new grads like Molly who are entering critical care areas, the ICU and emergency department have developed a two-step integration program. Through innovative planning using the Nursing Resource Team (the hospital’s centralized staffing pool) new grads begin their learning and mentorship in a number of medical and surgical inpatient units across the Health Centre. Sandra Lenarduzzi, Manager

St. Joe’s has recently hired their first new nursing grad, Molly Magee, into the intensive care unit, typically designated for experienced nurses.

of St. Joe’s Nursing Resource Team says their focus is to develop critical thinking, organizational and clinical skills as well as learn hospital-specific processes and policies. “This in turn gives them a solid foundation on which their critical care skills will be built,” Lenarduzzi adds. Although the ICU is traditionally seen as an environment for more seasoned and experienced nurses, Magee feels, based on her experience, new grads can learn the necessary skills and tricks of the trade to be successful in critical care. “It really depends on the person – you need to be really motivated and ready for a challenge to

work in the ICU.” Magee says St. Joe’s has provided her with the support while the ICU team has really involved her in opportunities where she can observe and learn. She also credits her preceptor with helping to ease her transition into the ICU. “I enjoy working so closely with the interprofessional team members here (in the ICU) and there is a really good approach to collaborative care – the staff here is great and I never feel alone. I feel prepared to be in the ICU.” Michelle Tadique is a Communications Associate at St. Joseph’s Health Centre in Toronto.


Hospital News, August 2009

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Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

The anatomy of an emergency room move: Scarborough hospital opens new ER By Cindy Woods

I

t takes years of planning and attention to a myriad of details to successfully pull off a major move from one operational Emergency Department to a new one. That’s exactly what happened July 8 at The Scarborough Hospital (TSH) . The transition from the old ED, built in 1957, to a state-ofthe-art ED in the hospital’s new $72 million Emergency and Critical Care Centre required precision, timing and strong communication between teams made up of staff, physicians and external consultants. Those teams involved an eclectic group of professionals, from the movers, general contractor EllisDon and emergency medical systems to information systems, security, facilities, housekeeping, pharmacy, nursing, physicians, porters, diagnostic imaging, registration and bed allocation. “All staff involved supported each other, and worked as a well-orchestrated team with lots of communication,”

says Louise Leblanc, Director of Patient Care for Emergency (Transition), who has worked at TSH for 37 years. “I am not aware of too many hospitals in Ontario that have gone through a similar move, when two EDs are operational at the same time.” The time of the move was confirmed for 11:30 p.m. on July 7, despite a last-minute arrival of a CTAS Level 1 patient. “The only glitch we had was that cardiac presentation to the old ED just two minutes before closing it down,” explains Kiki Ferrari, Acting Patient Care Director for Emergency and Urgent Care. “We provided the care the patient needed in the old ED and transferred him to the new ED. The outcome was very good.” By 12:15 a.m., the lights of the old ED switched off and the lights on the new ED were switched on. Nursing and physicians were ready for both EMS and walk-in arrivals. TSH’s new Emergency Department is 23,000 square feet compared to only 8,000

Setting up as the new Emergency Department at The Scarborough Hospital officially opens to patients are, from left: Jannine Bowen, Patient Care Manager; Vani Muthulingam, Unit Clerk; and Caroline Howard, Nurse. Photo credit: William Meijer. square feet in the old ED. There are five care zones -- pediatric; rapid assessment; critical care; acute care; and ambulatory care -- each designed to be selfcontained with their own nursing stations and separate patient rooms.

The new ED’s first walk-in patient was impressed with the department’s size, cleanliness and friendly staff. Adel Tofiq was accompanied by his wife, Laila Azizi, when he presented to the triage nurse at 11:36 p.m. “This is great. How often do

you come to the Emergency and not have to wait,” Adel says. “I can’t believe how quickly I was seen. This is a great department.” “We’re still on a high; the staff is elated at the new environment,” says Ferrari. “We’re tweaking things as we go along, tracking and monitoring our set-up to ensure that areas are doing what they’re supposed to do. I expect this ‘tweaking’ will be ongoing for six months.” Ferrari offers sage advice to other hospitals that may be planning similar moves: “Always focus on providing better patient care when designing a new space. If you focus on that, you’ll come out with a really good design that will lead to better outcomes,” she says. “Be patient, because there are a lot of details involved. And always involve as many frontline staff as you can in all processes. That was the key for us.” Cindy Woods is a communications consultant with The Scarborough Hospital.

New trauma website will focus on injury prevention and education By Lisa Dutton

T

rauma continues to be a leading cause of death and disability in children and teens. Today, we see over 15,000 cases a year in the Montreal Children’s

Hospital (MCH) Emergency Department. MCH Trauma hopes that by launching their new website it will give the hospital an edge on diffusing information in many aspects of trauma care, injury prevention and education. They also

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hope it will foster important collaborations with community and regional partners. And with this hope in hand they aspire to reduce this staggering statistic.   “We work hard on both sides: providing tertiary level trauma care and injury prevention. We know that by transmitting information via the web we are going to reach people of all ages giving us a much more efficient and effective way of meeting the needs of children, teens, parents, coaches, teachers and many of our partners in the Quebec and Canadian trauma network,” says Debbie Friedman, MCH director of the Trauma Programs, which includes a specific Injury Prevention Program. “This is especially useful for geographi-

cal areas that are not easy to reach—possibly on a global scale. Community partners can then use our expertise to develop different programs.” As a tertiary-care Trauma Centre we have many areas of expertise from orthopedics to neurosurgery to burn to dental so the MCH Trauma group is able to provide clear, credible information. On a sleek and easy-to-navigate platform, the new website offers interactive tools to teach and guide. Educational information on trauma care, including topic-specific resource material developed by the trauma programs, is also readily available. And a section designed for health professionals, including researchers, will allow them

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access to important information on trauma—including helping doctors make a decision whether they can treat a patient themselves or transfer the patient to our institution. The new website has also given the MCH an excellent venue for distributing news and alerts, such as diving board or trampoline warnings, to the masses. The overall goal:  to increase the knowledge out there but also to encourage people to make informed choices. “We want to encourage activity but we also want them to be smart about it,” says Friedman. “At the end of the day I feel we make a difference and with the new website I think we’ll be making an even bigger difference,” she adds. “The web is an important step in the MCH Trauma story and we take tremendous pride in what we have accomplished. We have gone from a group of three health professionals in the late 80s interested in Neurotrauma Issue with a desire toJune provide better coordinated care, to five distinct programs with 30 different departments onboard today.” Lisa Dutton is the Manager of Public Relations and Communications at McGill University Health Centre.


Hospital News, August 2009

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Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

11

Ambulatory treatment centre helps lower emergency department wait times By Lindsey Dickens

I

n 2008-2009, William Osler Health System’s Etobicoke General Hospital had over 64,000 emergency department visits, making it one of the busiest community hospital emergency departments in the province of Ontario. Despite the high volume, according to the Ministry of Health and Long-Term Care’s Emergency Department Wait Times website, Etobicoke General has continuously posted wait times that are among the best in the province for those with less severe conditions. A major contributing factor to this positive wait-times performance is the Ambulatory Treatment Centre. The Ambulatory Treatment Centre (ATC) was created in the winter of 2007 and was set up in Etobicoke General’s emergency department. The ATC is a renovation from a previous model of emergency care, known as the Rapid Assessment Zone (RAZ), that has since had a remarkably positive impact on wait times and patient flow in the department. “The concept of the RAZ actually started in late 2003 in a two bed unit. It was successful in the flow of our ambulatory CTAS 3 patients so we expanded it to four beds and subsequently renovated to create the 14-bed ATC,” says Dr. Naveed Mohammad, Chief of Emergency Medicine at Osler. The ATC is intended for patients triaged as CTAS 3, 4, and 5 who were previously seen in the RAZ and Fast Track. But the ATC is a better use of space, staff time and patient flow and is able to provide faster, more efficient service for patients. Like urgent care, the ATC treats patients with urgent but non life threatening injuries, such as abdominal pain, minor shortness of breath, fractures and urinary tract infections, plus many more aliments, injuries and infections that could potentially progress to a serious problem requiring emergency intervention. Unlike many urgent care clinics that have set times, the ATC is open 24/7 just like the emergency department. As well, unlike most urgent care clinics, which typically treat those triaged as CTAS 4 or 5, the ATC also treats those that are categorized as CTAS 3; however, all of those who come to the ATC must first be triaged through the emergency department. Upon entering the emergency department at Etobicoke

General, patients are met by a triage nurse. Based on the acuity of their conditions, patients are directed to the acute care area or the ATC waiting room, a separate space down the corridor from the main emergency department, to wait for their turn. The ATC treatment area has 14 beds, where various tests, reassessments and ECG’s take place. It also has an eye room, a suture room, a fracture room, and a women’s health room. There are also four chairs for patients with IV medications or waiting for certain results. Once all tests and assessments are completed, they return to the waiting room to wait for results. This helps open bed space and accommodate the flow of patients in the area. Roughly, 80 per cent of emergency patients are triaged into the ATC daily. The ATC is staffed by experienced and skilled nurses, physicians, and administrative staff, including a clerk, a Resource Nurse, two Registered Nurses (RNs), a Registered Practical Nurse (RPN) and a waiting room RPN. The waiting room RPN is dedicated to meeting the needs of the patients waiting for results, continually checks the vitals of patients, communicates with patients and their families, and follows up with the medical team with any worsening conditions. According to Lorrie Halliday, the Interim Director of Emergency Services, it is the nurses which make the ATC so successful. “It is all about patient flow,” she says. “With such high patient volumes, our nurses work in a very challenging environment. Often there are 30 emergency patients waiting for hospital beds each day and they make it happen with minimal patient complaints.” Erica Coobs, Acting Patient Care Manager, Emergency echoes Halliday’s sentiments. “We have excellent doctors and nurses who are committed to providing the best possible patient care each and every day. Patients are most satisfied when they know staff are doing their best to minimize the time spent in the emergency department.” The ATC has a very good working relationship with diagnostic imaging, the laboratory, and other hospital departments and services which help manage the flow of patients through diagnostics and treatment. Lindsey Dickens is a communications student at William Osler Health Centre.

Ambulatory treatment centre nurses, Bernice, Bridgitte, and Karen are committed to providing the best possible patient care each and every day. Patients are most satisfied when they know staff are doing their best to minimize the time spent in the emergency department.

APPOINTMENT NOTICE

Dr. Eric Fonberg

Paul McDevitt

Ontario Shores Centre for Mental Health Sciences (Ontario Shores) is pleased to announce the appointment of Dr. Eric Fonberg to Chair of the Board of Directors and Paul McDevitt to ViceChair. As Ontario Shores embarks on the next part of its journey to implement its mission, vision and strategic directions, Dr. Fonberg and Mr. McDevitt are well positioned to support the organization as it continues to build on its exemplary mental health care, research, education and advocacy initiatives. Dr. Fonberg is currently an emergency physician at Rouge Valley Health System. He has held consultant and senior management positions including roles in healthcare at Ernst & Young Management Consultants, Chief, Emergency Medicine and Medical Program Director at two Toronto hospitals as well as management positions in the insurance and biotechnology industries. Mr. McDevitt brings more than 25 years of senior management experience in the communications technology industry. He is currently Director, Marketing at Cisco Systems Inc. For the last six years, he has been a governor on the Board of Centennial College and served as their Chair. He joined Ontario Shores’ Board of Directors in June, 2007 and is currently Chair of the Audit Committee. Ontario Shores is a public hospital providing a spectrum of specialized assessment and treatment services to those living with complex and serious mental illness. Exemplary patient care is delivered through safe and evidence-based approaches where successful outcomes are achieved using best clinical practices and the latest advances in research. Patients benefit from a recovery-oriented environment of care built on compassion, inspiration and hope.


12

Hospital News, August 2009

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Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

New intensive care unit means better patient care By Stefanie Kreibe

Y

ork Central Hospital’s Intensive Care Unit (ICU) has moved up. literally. The hospital’s spacious new ICU is housed on the top floor of the hospital’s new Town of Richmond Hill Wing. The newly opened ICU currently offers 18 private patient rooms with the ability to gear up to 22, in the future. “When a patient is in intensive care, it’s a very anxious time for patients and family members,” says Linda Myles, Acting Program Manager, ICU and Ambulatory Care. “The new ICU unit provides the team with an excellent environment for providing compassionate and expert care. Natural light and large private rooms make for a more positive experience for patients and family members.” The old ICU was originally built in 1974 for a much smaller local population. Now serving more than 1,100 patients in a year, the former 10-bed unit offered only two isolation rooms and had curtains dividing the remaining 8 patients. In recent years, the hospital added an additional four bed satellite unit, which was inconveniently located on a different floor from the main unit. In addition to the main and satellite units, ICU patients were also cared for in beds borrowed from the recovery room and the emergency department.  The new space offers a large, bright working area with

Sean De Jardine an RN in York Central Hospital’s spacious new ICU works with one of the new touch screen monitors which are in each patient room. The new area offers bright natural lighting and views of the local conservation lands from most patient rooms. wide halls, plenty of storage space and large windows surrounding the entire unit. Nine rooms are negative pressure rooms and the unit features two airborne infection isolation rooms. Caring for intensive care patients involves not only the patient, but the families as well. With this in mind, the new unit also features two family waiting rooms, one with a microwave and refrigerator for visitors use. Each patient room offers private comfortable surroundings while still providing easy access to patients and the capability to ventilate each

patient with an oscillator, if necessary. New touch screen monitors provide easier input and documentation as well as links to clinical resources in every room. The hospital has taken some key measures in ensuring the transition to the new space is a smooth one, not only for the families of patients, but for the staff and physicians who work there as well. The unit has a large conference room that can be divided for presentations and educational sessions as well as new specialty beds including a motorized bariatric bed which reduces the strain on staff. 

“The new unit is three times the size of the former area,” says Sean De Jardine, RN in the ICU. “It’s great working in the new and expanded space. The new environment and increased natural lighting makes for a much nicer day at work.” While working, every nurse and physician carries a portable phone, making communication across the department easier. Also helping to make the transition to the new expanded unit smoother is the addition of new permanent staffing including dedicated Respiratory Therapists and

ICU Assistants to help nurses. The unit also hosts a Clinical Educator, Clinical Practice Leader, Pharmacist, Dietician, Physiotherapist and Social Worker and enough space and computers for them to work in the area when they’re not at the bedside. Other hospital services available to the ICU include Professional Practice support (including support for those nurses seeking specialty certification from the Canadian Nurses Association). The team also includes Speech and Language Pathologists, Wound care Specialists, Spiritual Care (with community support from many faiths and denominations) and Infection Control Practitioners. The new space also enables the ICU Clinical Director, Manager, Educator and Clinical Practice Leader to be accessible with offices right in the unit. For nursing staff looking for an opportunity to expand their expertise, opportunities exist to work on the Critical Care Response Team (CCRT), a team that follows the progress of patients once discharged from ICU to other care units for a period of time, as well as serving as a resource to all departments when they have concerns about a patient. “Our ICU is one is the best kept secrets. We’ve always had the staff and resources to provide top notch ICU care, but we now have a brand new facility in which to provide that care. It’s modern, spacious and beautiful. Having worked and visited dozens of intensive care units in the GTA and US including Harvard’s Massachusetts General Hospital, I can truly say that we have one of the nicest ICUs to work in. It won’t be a secret too long,” says Dr. Eric Chu, Clinical Director of Intensive Care at York Central Hospital.  York Central Hospital is a large, full-service community hospital with over 69,000 visits annually to its emergency department, serving a population of more than 400,000 in Southwest York Region and beyond. The hospital is located in one of Canada’s fastest growing communities. With a compliment of 472 beds, the hospital is home to the District Stroke Centre, York Regional Chronic Kidney Disease Program, and York Region Domestic Abuse and Sexual Assault Care Centre. For more information visit www.yorkcentral.on.ca Stefanie Kreibe works in communicationss at York Central Hospital.


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Propelling lives through innovations in medical tranpsort Continued from page 1 decades. It now stands at the cusp of a new frontier in medicine,” says Dr. Christopher Mazza, trauma physician and the president and CEO of Ornge. “This company is on the forefront of a movement that says we can provide a level of care that meets or exceeds that within bricks and mortar, anytime, anywhere. It’s a very modern concept, and one that quite simply did not exist in the past,” he adds. Calls for transport are taken at Ornge’s sophisticated communications centre. The flight and pediatric transport paramedics who respond are highly skilled, and undergo rigorous and ongoing training at the Ornge Academy of Transport Medicine. They are able to administer a wide variety of drugs and carry out complex medical procedures, all within the highly challenging atmosphere of a moving vehicle. Calls are triaged 24/7 by a transport medicine physician, or “doc in the box,” who also provides front-line staff with medical guidance and expertise. Ornge responds both to onscene trauma calls and requests from medical facilities to trans-

Critical care flight paramedic Marcie Beaudoin and former patient Caylen Laberge are reunited at Ornge’s Ottawa base. port patients to more specialized centres. Caring for such vulnerable patients requires both medical expertise and a true passion for and dedication to helping those in need. In Caylen’s case, the doctor’s relief was palpable when Ms. Beaudoin and Mr. Auger arrived at the local hospital. “Shock had set in, and the extent of his injuries made

starting an airway quite a challenge,” Ms. Beaudoin says. Damage from the lawnmower’s blades had left no teeth, lips or bones, which would normally be used to help establish an airway for Caylen. Ornge’s paramedics were able to successfully establish an airway, and to insert an intravenous needle directly into the child’s leg bone to help stabilize him

with the replacement of vital fluid and blood. After he was flown there by an Ornge helicopter, the skillful team at Ottawa’s Children’s Hospital of Eastern Ontario reattached Caylen’s arm, and it has completely healed. The four-year old has made a remarkable recovery, and is a precocious little boy who loves hockey and playing with his

siblings. Every year Ornge transports more than 18,000 patients, responding to calls everywhere from urban centres to the remotest reaches of northern Ontario. Yet it remains one of the best-kept secrets of the health-care system. “When we reach people they are often at their sickest and most vulnerable. Many of them will never know who it was that took care of them, and in many cases saved their lives,” Dr. Mazza says. The paramedics who treated Caylen, however, were thrilled to have the opportunity to reunite with the boy whom Mr. Auger calls a “miracle.” Caylen’s father, Gus, says the Laberge family feels the same way about Ornge. “We think about them a lot, because if it wasn’t for them, he wouldn’t be here.” If you’d like to share your story about being transported by Ornge they’d love to hear it. You can e-mail them at media@ ornge.ca, or call them at 647428-2107. Lori McLeod works in media relations at Ornge.

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Hospital News, August 2009

Improves efficiency in busy Emergency Room By Lisa Dutton

T

he Montreal Children’s Hospital (MCH) ER is busier than ever. In three years, the volume of patients has jumped 10 per cent to over 70,000 in 2006-2007. To cope with the ever-increasing number of children seeking care, the ER team has introduced a number of measures designed to ease wait times, improve quality of care and improve efficiency.

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The Fast Track System is designed to make sure children seeking urgent care are seen immediately and those seeking non-urgent care don’t bog down the entire system. Children with colds, slight fevers, warts or sore throats are deemed nonurgent cases or categories four and five. With the introduction of the Fast Track System a physician will see them in a separate part of the ER. The hospital hired an extra doctor to staff the Fast Track System, which operates most days between noon and 4 p.m. and between 6 and 10 p.m. “We started the Fast Track System in September to get it up and running before the RSV and gastro seasons hit us,� says Louise Murray, ER Head Nurse. “The primary goal is to decongest the ER. Non-urgent cases are not our priority, but we had to find a way to deal with the sheer volume of these patients. If we don’t deal with nonurgent cases, they end up taking over every available exam and waiting room in the ER slowing down the entire process.� Only 40 per cent of the children seen in the ER are true medical emergencies. The other 60 per cent of children need medical attention, but medical attention that would be more logically provided in a clinic, or the office of a family doctor or pediatrician. However, parents find it near impossible to find a pediatrician or family doctor accepting new patients and clinics aren’t always able or willing to treat children, and if they will treat kids they aren’t open evenings or weekends. So, the only place for worried parents to take their child is the ER. “We believe the Fast Track System will improve and maintain the service we provide the community,� says Dr. Harley Eisman, Director of the ER. “The MCH has pledged never to turn patients away because we know they have nowhere else to go.�

tem. When children arrive at the ER a nurse immediately assesses them. Those who are critically ill are whisked in to the ER without delay. No time is wasted with registration and mountains of paper work. “We know parents tend to drive their critically ill children to the hospital rather than call an ambulance. The Pre-triage system makes sure these children are treated stat,� says Ms. Murray. Also in Pre-triage, when the nurse decides a child is in need of urgent care, he can be sent to the head of the line. The nurse is also able to quickly divert non-urgent cases to the Fast Track System.

Re-evaluation system Another measure recently introduced by the ER is the Reevaluation System. A nurse is assigned to reassess patients in the waiting rooms to make sure children are in stable condition. If a child’s condition has deteriorated, he will be bumped up and seen faster. “It is reassuring for parents to know a nurse is on hand to make sure their child is still doing okay,� says Ms. Murray “At times the wait to see a doctor can be long, and parents may feel they’ve been forgotten. The Reevaluation System makes sure all children receive proper care in as timely a manner as possible.�

Child Life Educator The wait times in the ER can be long and frustrating for children and parents. The ER eagerly welcomed a second Child Life Educator to its team during the evening shift. The Educator is skilled at distracting and reassuring children by reading, drawing or doing other activities to help calm frayed nerves. “We are confident the new measures we’ve introduced will help make the ER more efficient and it will help our healthcare professionals better cope with the burgeoning number of children seeking medical attention,� says Dr. Eisman. “In the end, we all want what is best for the children seeking medical care.� “The ER is the heart beat of the hospital. We need to keep finding innovative solutions to help the ER team cope,� says Ms. Murray. “The entire MCH has to get involved so that we can find new ways to work together for the benefit of the children.�

#,)%.4-3& Lisa Dutton is the Manager 02/*%#40LANNED'IVING!D of Public Relations and Pre-triage system Communications at the McGill $/#+%44"$ Also in September, the ER University Health Centre. implemented a Pre-triage sys3):%vW8vH


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Ontario’s Critical Care Information System: The journey to knowledge By Dr. John Muscedere

W

ith the ability of modern medicine to treat more complex illnesses combined with an aging population, Intensive Care Unit (ICU) beds have come to account for a significant proportion of all acute care beds and utilize significant hospital resources. In Ontario, there are approximately 1900 ICU beds in 116 hospitals across the province. Approximately 100,000 Ontarians with a critical illness are treated in the province’s ICUs each year. Until recently there was little information as to the utilization of critical care beds and the types of patients that were being treated. Moreover, the ICUs in the province were mostly working in isolation and not as a provincial system. To meet the challenges of increasing demands for critical care resources it became apparent that administrators and critical care practitioners needed access to consistent and real-time information on the quality, access and outcomes of the province’s critical care resources. The management of complex systems requires reliable information that is pertinent and up to date, preferably in real time. The Critical Care Information System (CCIS) was developed to meet the needs of both administrators and front line staff through extensive consultation with key stakeholders including critical care clinicians. Its purpose was to foster the development of the province’s ICUs into a provincial critical care system. The CCIS is an international leader with respect to the information collected and the extent that it is utilized. We now have insight into the treatment of critically ill patients which was previously unavailable. This information will be used by the Critical Care Local Health Integration Network (LHIN) Leader table, the Ministry and hospitals to guide changes to critical care delivery in the future. The CCIS is fully operational in 199 units across the province. Access to this information is incredibly important and helpful in understanding our complex system, identifying areas for improvement, and as an aid to decision making. One of the most useful indicators is realtime information on the occupancy of the province’s critical care units to determine the number of ICU beds being utilized at any given time. Not only can we see the picture for the province, but occupancy rates

can be determined regionally, by admitted to critical care beds. hospital or down to individual At the initiation of CCIS only units. Recent enhancements basic clinical data was collected allow sites to record the reasons but recently data elements have why beds are unoccupied (i.e. been added to determine the booked for scheduled admisseverity of illness for each ICU sions or closures due to lack of patient, formally known as the staff or resources.) Multiple Organ Dysfunction Outside of resource utilizaScore (MODS) on admission. tion, the CCIS has recently MODS is a validated scoring evolved capture the charsystem that allows clinicians to 08-646to TR Hospital newsad:07-014 Hospital newsad 3/20/08 acteristics of patients who are determine the severity of illness

of critically ill patients and for the comparison of severity of illness between ICUs. Further, the degree of resource utilization over the course of patients’ ICU stays is captured through the recording of life support interventions (i.e. mechanical ventilation, dialysis, central lines etc.) and need for nursing interventions. By capturing this 10:07 AM Page 1 data, it is possible to describe in

detail the resources critically ill patients require in Ontario. The CCIS also captures patient outcomes such as mortality, length of stay in ICU and duration of mechanical ventilation. In an era of increasing recognition of the importance of preventing harm to patients, this information is important from a patient safety perspecContinues on page 16

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Pediatric Critical Care Response Teams: Prevention at its best By Dr. David Creery

I wonder what’s wrong. This little girl was fine last night, but now she’s far too sleepy. I wonder what I should do.” These were the thoughts running through the mind of a nurse on the surgery ward recently at the Children’s Hospital of Eastern Ontario (CHEO). Her patient was a young girl who had had a tonsillectomy two days before, but this little girl wasn’t recovering the way post-op tonsillectomy patients usually do. The nurse had paged the surgical resident, who had come right away. Together they tried to figure out what was wrong, but they were stumped. They decided to activate CHEO’s SPOT team, the local name for the hospital’s Pediatric Critical Care Response Team. SPOT stands for Speed, Proactive, Outreach, and Teaching, reflecting the four key components of the program. The SPOT team arrived within a few minutes, and began working with the ward team to problem-solve what might be wrong. Together, they decided to try a medication that reverses the effect of pain controlling

medications, and after it was given, the child woke up almost immediately and was back to her old self. The sense of relief in the room was palpable, and the child’s mother was delighted with the way the teams had worked together to help her daughter. Stories like this are very common in pediatric health care. In situations like this, a safe, quick, proactive and effective response is needed which is why the Pediatric Critical Care Response Teams (PCCRT) program was implemented in Ontario. Early intervention in the course of a patient’s deterioration reduces resource utilization, but more importantly improves patient outcomes and reduces suffering. The central purpose of PCCRTs is to allow highly skilled acute care providers to arrive at an unstable patient’s bedside as early as possible in the course of the deterioration, so that problems can be solved before they become really severe. Acutely ill children are a highly vulnerable population who are ideally suited for the beneficial impact of PCCRTs. Children often have respiratory deteriorations before cardiac ones, and these teams

are well-equipped to deal with acute respiratory crises. Since 2007, CHEO, in partnership with three other pediatric academic health sciences centres in Ontario has been working on improving the safety and outcomes of hospitalized children through participation in Ontario’s Pediatric Critical Care Response Team pilot project led by Dr. Desmond Bohn (Hospital for Sick Children in Toronto). In addition to the PCCRT program, all sites are also participating in a unique extramural PCCRT program, which allows a referring physician from a non-pediatric centre to rapidly access a Pediatric Critical Care specialist through a one-number-to-call service provided by CritiCall. The SPOT team aims to not only provide care in a timely, preventative manner to at-risk populations outside the Pediatric Intensive Care Unit (PICU), but also to capacity-build through care-giver education and skillsbuilding. Residents now believe that their educational experience has in fact improved since the introduction of SPOT, because they learn through first-hand experience and observation. A survey of health-care providers

and the users of CHEO’s SPOT team shows some interesting and encouraging results, such as: • Ninety-five per cent of caregivers felt the SPOT team took time to share their knowledge and skills, and • Ninety-eight per cent felt that the SPOT team is a welcome addition to their work and enhanced their feeling of confidence as they went about their work. • Preliminary local data has shown a decrease in readmission rates to the PICU (bounce-back patients), a trend towards decreased inhospital cardiopulmonary arrests (code blues), and a statistically significant decrease in PICU mortality among patients admitted urgently to the PICU from the wards. I am proud to be part of a project that is seeing our Ontario pediatric patients and their families benefit from a unique and successful model of collaborative care. Dr. David Creery is the Medical Director for Pediatric Critical Care at the Children’s Hospital of Eastern Ontario in Ottawa.

Ontario’s Critical Care Information System: The journey to knowledge

Continued from page 15

tive as well. The three main indicators of patient safety that are recorded are ventilator associated pneumonia, central line infections and unplanned extubations. These are captured since there are well recognized strategies that can be utilized to prevent these occurrences. Using a non-punitive approach, the role of the Critical Care LHIN leader is to work with hospitals to track these quality indicators over time, to look for areas for improvement and to facilitate interventions that could be put in place Although CCIS is in its infancy, it is hard to imagine the management of a vital resource such as critical care without the crucial information that CCIS provides. As time goes along, Ontario’s CCIS will assume increasing importance and will be the cornerstone of the province’s critical care system. Dr. John Muscedere is a Critical Care LHIN Leader of the South East LHIN and Physician at Kingston General Hospital.

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Mask fit testing important part of pandemic planning By Mark Palmer

T

he emergence of the Influenza A H1N1 virus has triggered a beehive of activity at each Ontario hospital around pandemic planning. With each pandemic plan comes a big to-do list – communication, education, screening, inventory checks, and much more. But perhaps one of the most involved action items on any pandemic plan is mask-fit testing. The use of masks at healthcare facilities during heightened stages of a pandemic is no doubt an effective infection control method, but studies document that proper fit testing enhances the effectiveness of masks.  But ensuring every employee is up to date for mask-fit testing when your hospital has hundreds or thousands on the payroll can be an onerous task and place great pressures on occupational health staff. Toronto’s West Park Healthcare Centre has employed a novel way to ensure all staff are mask-fit tested in short order. Its occupational health and safety staff teamed up with the hospital’s revenuegenerating division known as

Pro Active Healthcare - a wellness and rehabilitation clinic located within the hospital - to rapidly mask fit test hundreds of employees. Normally a provider of personalized therapy including acupuncture, chiropractic, chiropody, physiotherapy and occupational therapy, Pro Active expanded its mask-fit testing services for the Centre and is now offering similar service to hospitals across the province. As a result Pro Active has performed approximately 550 mask fit tests at West Park over the last four months to ensure all staff were properly fitted – no small feat considering staff schedules and the time it takes to conduct each test (15 minutes). “Pro Active worked quickly and diligently to assist us to meet the requirements and establish an effective ‘testing’ environment,” says Donna Renzetti, West Park Vice President, Programs. “Working collaboratively allowed us to establish what needed to be done quickly and effectively – namely processes and a database to track compliance and meet the requirements.” For occupational health and safety staff, the partnership with

Pro Active on mask-fit testing had a huge impact. “The partnership helped us to streamline the process and establish a database to keep abreast of the current mask-fit status of staff and physicians. This will assist us to ensure that we have the required data when it is needed,” says Peggy Craig, Manager of Occupational Health and Safety at West Park. “Monthly mask-fit test status reports keep the issue at the forefront.” Pro Active uses quantitative mask testing – which determines the fit of a mask with a particle counting device that measures the concentration of microscopic particles that exist in ambient air. The measurement is made while the person performs dynamic movements and/or breathing exercises resembling those experienced in the workplace in order to stress the respirator seal. Results are immediate and deliver either a ‘pass’ or ‘fail.’  Word of Pro Active’s successful partnership with West Park’s occupational health and safety department spread fast, prompting other health-care facilities and organizations to call Pro Active about setting up mask fit testing for their own

West Park Pro Active Healthcare kinesiologist Emily Watters (right) conducts a mask-fit test on West Park employee Besi Manzo. organizations. “Through this collaboration we have established an effective way to provide testing for high volumes and track employee testing data so any organization is always on top of this important issue,” says Dave Ursomarzo, Manager of ProActive Healthcare. Thanks to the collaboration

between Pro Active and occupational health and safety, West Park Healthcare Centre is on top of mask-fit testing, helping to fulfill its ongoing commitment to patient safety and a healthy workplace. Mark Palmer is a Communications Specialist at West Park Healthcare Centre.


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Hospital News, August 2009

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Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

Ontario’s Critical Care Strategy: Progress and evolution By Dr. Bernard Lawless

I

n 2006, Ontario’s Critical Care Strategy, was initiated to make system-wide improvements in access to high quality critical care across Ontario. Since that time, tremendous progress has been made in transforming how health-care providers and health system planners regard critical care resources and the provision of care to critically ill patients. Whether its working to fulfill accountabilities for the Wait Time Strategy or understanding patient flow in emergency departments, hospitals have a better appreciation regarding the importance of access to critical care resources and how even just a few extra unexpected critical care patients can bottleneck access to services across the rest of the hospital, the Local Health Integration Networks (LHINs), or the province. The transformation in organizations with the respect to the delivery of critical care services across Ontario did not happen overnight, but the success and progress has mostly occurred due to the involvement and support of many different levels of stakeholders and the partnerships that have been

nurtured. Ontario’s Critical Care Strategy and its activities continue to be supported by the Ministry of Health and Long-Term Care’s Critical Care Secretariat. Extensive partnerships exist with the LHINs and the hospital organizations. Our coaches bring front-line leadership and ideas to peer organizations and bring back learning to their local environments. The Provincial Critical Care LHIN Leaders Committee continues to bring front line expertise to advise on strategic direction and each Critical Care LHIN leader has an integral role working in partnership with each hospital on all elements of the strategy in their respective LHINs. Many hospital and LHIN administrators, clinicians and other stakeholders advise and support the initiatives of the strategy through subcommittees and focus groups that report to the Critical Care Secretariat. The Critical Care Secretariat has also formed key partnerships with other organizations both internal and external to the ministry. As provincial lead I am proud to highlight a number of notable milestones: • Eighty-six new critical care beds were funded to support expanded capacity. These beds have been opened across

35 hospital corporations in all 14 LHINs. Twenty of these beds have specifically been targeted to support chronically ventilated patients. Funding was provided to support over six hundred and fifty nurses get trained in critical care. Much of the reported funding was used to give nurses access to the E-learning program developed in partnership with Durham College which also adheres to the Critical Care Nurse Training standards that were developed. The number of post graduate training opportunities for critical care physicians was more than doubled. Twenty seven adult Critical Care Response Teams (CCRTS) have been mobilized across 24 hospital corporations for a minimum of one year in operation. CCRTs help to treat patients who show early signs of potential deterioration but are located outside of the critical care unit. This can result in a patient avoiding the need for intensive care unit (ICU) admission or having a shorter length of stay in the ICU. Four pediatric Critical Care Response Teams have been providing 24/7 assistance to any physician in the province

Dr. Bernard Lawless is the Provincial Lead (Ontario) for Critical Care and Trauma. caring for a critically ill pediatric patient. • Performance Improvement Coaching Teams have been deployed more than 90 times to empower critical care units to develop unique solutions related to a broad range of issues including patient flow, communications and end of life issues. • Four hundred and forty community physicians were offered ACES level training courses and 100 clinicians were trained in End of Life Communications in Partnership with the Canadian Resuscitation Institute. • Implementation of wave

seven of the Critical Care Information System is complete. We are now collecting information on ICU resources in the province from 199 critical care units. • The provincial implementation of the Surge Capacity Management Program commenced in April 2009. This program will provide hospitals with a common framework to better manage surges of critically ill patients locally, will promote system integration across regions and will allow for a coordinated provincial response to any increase in patient volumes where demand exceeds resources. Ontario’s Critical Care Strategy has achieved key success in a relatively short period of time. These accomplishments have been recognized at international health-care policy and scientific meetings and several jurisdictions are looking to Ontario as a leader in health-care system transformation. It is clear that the benefits of improving the critical care system are not only evident in critical care units, but are widespread across a patient’s continuum of care. The successes that have been realized are shared by the numerous partners across that continuum of care who partner with Ontario’s Critical Care Strategy to improve patient care in Ontario. Moving forward, Ontario’s Critical Care Strategy will continue to find success built on these partnerships and keep the strategy rooted in its “ground up” architecture. Dr. Bernard Lawless is the Provincial Lead (Ontario) for Critical Care and Trauma.


Hospital News, August 2009

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Evidence Matters

19

Ultrasound in small emergency departments By Jeannette Smith

S

ince the 1990s, ultrasound has gained popularity in hospital emergency departments as a tool to help diagnose a range of conditions, things such as gallstones, abdominal aortic aneurysms, ectopic pregnancies, and trauma to the chest or abdomen. It’s a fast, non-invasive tool that enhances a physician’s ability to evaluate, diagnose and treat patients. In the past, the size and cost of ultrasound machines limited their availability and use. But recently, technical advances have led to the production of high quality, smaller, more portable equipment costing only a fraction of what ultrasound machines used to cost. Newer units can easily be accommodated in busy emergency or trauma areas. In the past, ultrasound was performed by highly trained radiologist specialists able to view, analyze and modify scans to optimize the diagnostic information. Now, with the introduction of newer portable equipment, many emergency physicians also perform scans. Questions have arisen about

the use of portable ultrasound by non-radiologists in smaller emergency departments where there may be a lower clinical prevalence of conditions for which ultrasound is used. Direct evidence from the literature concludes that ultrasound is an effective tool in small emergency departments for guidance with procedures such as central venous catheterization. Indirect evidence from research conducted in large urban hospital emergency departments concludes that physician-performed ultrasound is a valuable tool for diagnosing trauma, deep vein thrombosis, ectopic pregnancy, and abdominal pain. The key for physicians in small community emergency departments is continuing education, training, and re-training. At the present time there is no guidance for the maintenance of competence in this area from the Royal College of Radiologists, the American College of Emergency Physicians, or the Canadian Emergency Ultrasound Society (CEUS). However, many training opportunities are available. The Canadian Association of Emergency Physicians (CAEP) recommends that emergency

departments should have access to targeted ultrasound 24-hours a day, seven days a week and suggests that immediate access to bedside ultrasound enhances patient care and safety by expediting illness management and avoiding transfer outside of the emergency department for diagnostic procedures. They also recommend that targeted ultrasound training should be incorporated into emergency medicine residency programs, training guidelines be developed, and strongly encourages continuing medical education in emergency department ultrasound. CAEP offers a course entitled Emergency Department Targeted Ultrasound, a ninehour introductory course that teaches all the essential skills for ultrasound. This evidencebased course offers didactic and hands-on training in ultrasound physics, image generation and interpretation, ultrasound psychomotor skills, and indications for and limitations of emergency department targeted ultrasound. More information about CAEP courses is available at www. caep.ca.

Managing neuropathic pain

Every year, new medications appear on the market sparking hope that these treatment options will improve the quality of life for patients. However, sometimes evidence reveals that existing, tried and true medications are still the best option. Such has been shown to be the case when it comes to drugs for neuropathic pain. Neuropathic pain is a common, complex, and severely disabling condition caused by a dysfunction of the nervous system .One example of the disorder is phantom limb syndrome, which arises when a limb is lost through illness or injury. The brain can still receive pain messages from the nerves that originally transmitted impulses from the missing limb. People who suffer from neuropathic pain are often in agony. It diminishes their quality of life and places a burden on the health--care system. The primary goal of treatment is not necessarily to eliminate pain, but to make it more bearable. When CADTH was asked to examine the recommended treatment options, old and new, for neuropathic pain, their analysis showed that a class of antidepressant drugs that had been on

the market since the 1960s — tricyclic antidepressants (TCAs) — turned out to be the most clinically effective and costeffective agents for the first-line treatment of the condition. The CADTH assessment, Anticonvulsants, SerotoninNorepinephrine Reuptake Inhibitors, and Tricyclic Antidepressants in Management of Neuropathic Pain, found that TCAs, anticonvulsants, and serotonin-norepinephrine reuptake inhibitors have similar efficacy, but that starting treatment with TCAs was associated with improved health and fewer health-care costs. CADTH reports are available at www.cadth.ca. The Canadian Agency for Drugs and Technologies in Health (CADTH) is a national body that provides Canada’s federal, provincial and territorial health care decision makers with credible, impartial advice and evidence-based information about the effectiveness and efficiency of drugs and other health technologies. Jeannette Smith is a Stakeholder Relations Officer at the Canadian Agency for Drugs and Technologies in Health.


20

Hospital News, August 2009

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From the CEO’s Desk

Improving capacity at all levels of care: A collaborative approach By Malcolm Moffat

W

hen people are unable to move from acute care to a more appropriate health facility in a timely manner, the consequences are felt system-wide. Wait lists grow, emergency departments become over-crowded, and a lack of available beds result in slowed discharges and admissions. This critical issue has become a significant challenge to the Canadian health-care system. Recently in Ontario, all hospitals have incorporated a standardized provincial definition for this issue. “When a patient is occupying a bed in a hospital and does not require the intensity of resources/services provided in this care setting…, the patient must be designated Alternate Level of Care (ALC) at that time by the physician or her/his delegate. The ALC wait period starts at the time of designation and ends at the

time of discharge/transfer to a discharge destination... ” (Provincial ALC definition). Many hospitals have developed innovative strategies for reducing and managing the number of ALC patients. These include introducing education programs for patients and families, establishing dedicated ALC beds, and implementing patient flow policies. However, for a comprehensive resolution, health-care providers must continue to tackle this issue system-wide, in a collaborative and coordinated manner. Acute care, rehabilitation, complex continuing care, long-term care, mental health and other health- care providers need to work together to find practical solutions to this issue. St. John’s Rehab Hospital is playing a critical role. Together with North York General Hospital (NYGH), the hospitals have integrated their inpatient rehabilitation services into a focused, specialized program at St. John’s Rehab.

The Fourth

The partnership, formed in March 2008, allowed NYGH to convert its inpatient rehabilitation program into acute care space, thereby reducing wait times in their emergency department. St. John’s Rehab Hospital used newly added resources to admit patients with additional medical needs, and increase the occupancy of available inpatient beds. This innovative program represents one of Ontario’s first major health integration projects. It is an example of how hospitals and Local Health Integration Networks (LHINs) can collaborate to find practical solutions to the ALC challenges that affect all levels of health care, including post-acute hospitals. According to a report by the Greater Toronto Area Rehabilitation Network, 62 per cent of referrals from rehabilitation did not receive a response within a two businessday benchmark, and 31 per cent of these referrals received

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Malcolm Moffat is the President and CEO of St. John’s Rehab Hospital. responses three to ten days after the referral was sent. These statistics clearly demonstrate room for improvement in admission and discharge practices within rehabilitation and other postacute hospitals. To help facilitate a smoother process within our own walls, St. John’s Rehab embarked upon a pilot project in January 2009. Funded by the Central LHIN, the project expanded rehab therapy and admissions to seven days per week, and increased access to outpatient rehabilitation. With the ability to admit and discharge patients every day of the week, St. John’s Rehab can care for 6 per cent additional inpatients each year. This frees up space at acute care hospitals, allowing more patients to get the immediate care they need, while reducing their wait times. The pilot project quickly showed successful results: in less than a month, St. John’s Rehab eliminated its wait list for priority outpatient care, opening up space to improve the continuum of care. We also opened up weekend admissions and therapy, and reduced the wait time to be transferred from acute care to inpatient rehabilitation. On May 19, 2009, the Central LHIN announced that it would permanently invest $4 million per year in St. John’s Rehab to continue the expanded service.

This funding will allow our interprofessional team to provide the same excellent rehabilitation care every day of the week. Patients can be admitted from our acute care partners earlier, participate in rehabilitation sooner, and return to their communities healthier. St. John’s Rehab continues to focus on effective solutions to address the ALC issue. We have adopted LEAN thinking - a methodology that brings together teams of front-line staff to examine current processes and identify opportunities for improvement. A major goal is to determine how we can better reduce each patient’s length of stay. Within this goal, we are focusing specifically on admissions and discharge planning, and other aspects of the patient’s transition through the system. Although the issue of ALC presents many challenges, we look forward to developing additional partnerships that ensure patients receive optimal care in the most appropriate setting. Through continued collaboration, we can find innovative solutions that meet the needs of the health care system and, most importantly, help rebuild the lives of people who require our vital level of health care. Malcolm Moffat is the President and CEO of St. John’s Rehab Hospital in Toronto.


Hospital News, August 2009

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Hospital News, August 2009

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Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

Emergency preparedness training program gives staff the tools for success By Catherine Shannon

H

aving the right knowledge at the right time can help save lives, and this philosophy is at the heart of Mount Sinai Hospital’s innovative emergency preparedness staff training program. Whether it’s teaching staff how to recognize a suspicious package, react to a fire alarm, medical emergency or locate a missing patient, Mount Sinai’s Emergency Procedures Committee is dedicated to delivering effective training tools to everyone who works at the hospital – from frontline health-care providers to contract construction workers. “Everyone has a responsibility to know whom to call, and his or her own role during an emergency,” says Kim Parker, Risk Manager and Emergency Procedures Committee Chair. “During any emergency, our focus is on deploying staff to where they are most needed, so that we may continue to provide the best possible care to patients and their families.” Hands-on emergency response training, realistic mock scenarios, and computerbased learning modules are some of the methods the Committee has used to educate staff about what is needed to prepare for a crisis. Committee members work closely with managers across the hospital who have taken a leading role to ensure their staff are

Members of Mount Sinai Hospital’s 25-person Emergency Procedures Committee are dedicated to delivering effective training tools to all staff.

equipped with effective problem-solving and communication skills. “We’re a multi-faceted, 24/7 operation with over 4,000 employees, so we need to take into consideration how different people absorb information,” Parker explains. “Providing useful, accessible information to all staff is the foundation for an effective education program. By reaching more of our colleagues, we’re creating a safer environment for our patients and everyone who comes

through our doors.” One of the ways the Committee measures the success of the program is by staging mock emergency scenarios. A result of careful planning, staff have been challenged

Radiation and Nuclear (CBRN) contamination, and on the use of fan-out phone lists and emergency command centres. “Hands-on exercises are very important to staff,” explains Marcus Veytia, Mount

own work environment. The mock scenarios – especially evacuation drills – are great training because the skills are highly transferable to other situations.” Recently, the Committee planned and conducted a mock Code Amber (missing infant) exercise to test the skills of front-line and administrative staff in the Mother and Baby Unit. Security staged an abduction scenario involving two volunteer actors – one playing the role of the abductor and the other that of a distraught mother. From the initial announcement of Code Amber to the first search team locating the suspect and infant (a Labour and Delivery doll), two complete building searches were conducted in 21 minutes. “Observing the reactions of staff was eye-opening,” says Mark McCormick, Manager of Security. “Even the staff members who knew it was a mock exercise were visibly anxious but still incredibly focused on the task at hand. As a first Code Amber drill it was an exceptional performance.” Mock scenarios also keep policy-makers – including Emergency Procedures

Mock scenarios also keep policy-makers – including Emergency Procedures Committee members and Security staff – on their game in several “mocks” – some of which include Code Blue (cardiac arrest); Code Red (fire); Chemical, Biological,

Sinai Hospital’s Fire Marshal. “During a Code Red fire drill, for example, participants are shown how to react in their

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Committee members and Security staff – on their game. Following each drill exercise or emergency, a debriefing session brings together Committee members and other key players to analyze the processes and outcomes of the event, and work to ensure that procedures are improved wherever possible. “Knowledge gives you confidence,” says Parker, “and instilling that knowledge is the objective of our program.” Catherine Shannon is the Public Affairs Co-ordinator at Mount Sinai Hospital.


Hospital News, August 2009

www.hospitalnews.com

Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

23

Clinical resource team provides support during staff shortages By Shiela Olley

L

ike many other organizations, hospitals are around-the-clock operations. But unlike companies that can continue to do business when employees call in sick or take vacations, hospitals need to be properly staffed at all times in order to ensure patient safety. When more nurses are needed to fill shifts, temporary agencies are called in to support the clinical teams, which can add up to high costs and disruption to the day-to-day flow of the units. In 2008, William Osler Health Centre was relying heavily on agencies to help meet the health-care needs of a rapidly expanding patient population. In addition to the cost, managers were finding that nurses had to spend a great deal of time assisting agency staff with computer access and equipment use and performing tasks that didn’t fully maximize their nursing skills. To alleviate these concerns, Lorrie Halliday, Acting Director of Emergency Services, put forth a proposal to form a new support team as part of a broader strategy to address issues of access and flow at the hospital. The goal was to find an inhouse solution to the ongoing need for temporary help by creating a new staffing model that included registered nurses, registered practical nurses, personal support workers, orderlies, and clerical staff. The proposal was approved and Halliday, together with Elaine Harkiss-Laird, Director of Human Resources, devel-

oped a Clinical Resource Team (CRT) made up of 23 staff members who were interested in being part of the new service. The team also took on the coordinating of new graduate nurses, providing them with a three-month general medicine rotation and a one-month surgical rotation, with some nurses going into specialty areas such as paediatrics and emergency. Sixty new graduates will be joining Osler this summer. The idea of the CRT has caught on. Units began using the team to fill short-term vacancies, sick days and holidays. The staff assisted with screening and mask fitting to meet the H1N1 influenza requirements. And when the sinks in the Brampton Civic Hospital intensive care unit (ICU) were temporarily out of commission, the CRT was there to help provide personal care for patients. “This was a challenging time for the ICU. The CRT staff helped our team make patients and families more comfortable as they assisted with some basic care for ICU patients. Their assistance helped staff to feel supported as they provided patient care during this taxing period,” says Liz Cameron, Acting Director. Liz Buller, Senior VicePresident, Patient Services, agrees. “Lorrie and Elaine have done an amazing job pulling this together, using creative and nimble staffing solutions and working closely with the teams who use the CRT to make sure the CRT staff are treated well and recognized for how important they are to the whole

team,” she says. From January to June 2009, the CRT provided over 28,000 hours of service to clinical teams at both the Brampton Civic and Etobicoke General Hospital sites, and agency use dropped from an average of 15,078 hours per month to 7515 hours. This resulted in significant cost savings for the hospital. Last year, nursing agency costs were as high as $1.2 million per month, but have come down to under 600,000 in recent months. The program itself has proved to be a popular draw. Staff appreciate the special training, employee benefits and computer access offered at Osler while still having flexible schedules. The staff complement has grown to 95, some of whom are former agency nurses or care providers who previously worked in community settings. Grace Richardson was a personal support worker for five years before joining

Grace Richardson, clinical resource team member, assists with flu screening in the emergency department at Osler’s Brampton Civic Hospital. Staff on the Clinical Resource Team are able to provide temporary support to various departments across the health centre.

Osler and enjoys the exposure she now has to various departments. “I love interacting with different people and I like to talk,” she says, laughing. “Sometimes people need that… just know someone is there to

talk to them, or just to listen. When they’re in hospital, they need to feel they’re not alone.” Shiela Olley is the Senior Writer at William Osler Health Centre.


Hospital News, August 2009

24

www.hospitalnews.com

Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

Emergency department ultrasounds: saving time and lives By Karin Archer Myles

I

n an emergency department, time is of the essence. A quicker diagnosis can mean the difference between life and death, which is why physicians at Toronto East General Hospital (TEGH) are often now reaching for an ultrasound machine faster than a stethoscope and are national leaders in practicing this new technique. Abdominal pain is the most common patient complaint in an emergency department, yet the underlying cause can range from indigestion to an aneurysm. Narrowing down a diagnosis is often a matter of elimination and thanks to ultrasound, many life-threatening complications can be diagnosed faster than ever before. “Having the ability to use ultrasound in the emergency department is significant because it changes the way we are able to care for our patients,” says Dr. Paul Hannam, Chief of Emergency Medicine, TEGH. “There is better information available at the bedside. No single test is perfect, but using ultrasound adds another dimension to the

Dr. Paul Hannam uses the ultrasound in emergency for quick diagnoses. Photo credit: Karin Archer Myles.

clinical picture. In some cases, this can be lifesaving.” The Canadian Emergency Ultrasound Society (CEUS) is the national organization that oversees emergency ultrasound training in the country and is comprised of physicians who promote the safe and effective use of ultrasound. “The TEGH Emergency Department staff are among the leaders in emergency ultrasound in Canada,” says Dr. Peter Ross, President, CEUS. “All members of the department have taken a basic course in this subject. Much more importantly, they

have nearly all gone on to be certified by the CEUS as Independent Practitioners. This is an extremely noteworthy achievement, as most emergency departments have no more than a few of its members certified to this level.” The ultrasound machine, which is more compact than an average laptop, sits atop a metal trolley and can be easily manoeuvred throughout the busy halls of the unit. TEGH, which began using the technology in 2007, has two devices, which physicians use multiple times during their shift.

The scanners are used to rule out possibilities so that physicians can guide the timing of a definitive scan in radiology. “We use the scanners to make sure there isn’t an immediate danger to our patient,” says Dr. Hannam. “A CT scan provides greater detail, but it can take a few hours to perform the scan and get the results back. Emergency ultrasound allows us to say yes or no right away. We still rely on our colleagues in radiology, but we can make decisions in the emergency room with more confidence.” Emergency ultrasound focuses on the detection of certain urgent, life threatening conditions. For example, one patient walked into emergency and was complaining of pain in his abdomen and fainted. The physician, who would have previously sent the patient for a CT scan, used the ultrasound and saw a large aneurysm which was slowly leaking. A leaking aneurysm can become fatal within three hours without treatment. The patient, who wasn’t showing classic symptoms of an aneurysm, was immediately transferred to the operating room for surgery and

was able to go home a week later. “Ultrasound is transforming the way emergency medicine is practiced in Canada,” says Dr. Ross. “What makes the Canadian experience unique is the rigorously high standard with which ultrasound education has been disseminated across the country.” Currently, there are 27 emergency physicians who have voluntarily completed the CEUS courses and can now call themselves Independent Practitioners at TEGH. Dr. Francis Sem, Ultrasound Education Coordinator at TEGH, has been the driving force behind much of this success. “The docs have really embraced this and all of us are doing it,” reveals Dr. Hannam. “This is most beneficial to the community as it’s rare to see such high and consistent standards with a new, nonmandatory practice. Emergency physicians like it because it works.” Karin Archer Myles is Communications coordinator at Toronto East General Hospital.

Sunnybrook emergency physician serves as consultant in Romania By Laura Bristow

D

r. Valerie Krym, a Sunnybrook emergency physician,

received an invitation from the Romanian Ministry of Health to assist with development of emergency medicine on a national level. Dr. Raed Arafat,

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the Romanian Undersecretary of State for Health asked Dr. Krym to come to Bucharest, where she served as a consultant from April 23 – May 2, 2009. This consultancy builds upon Dr. Krym’s successful work in emergency medicine capacity-building in Cluj-Napoca, Transylvania, Romania over the past four years. Dr. Krym has led teams of fellows, residents and nurses to Cluj to assist with advancement of emergency care in the former communist country. Emergency medicine projects have included needs assessments, physician and nursing education, triage implementation and research projects. Upon arrival, Dr. Arafat provided Dr. Krym with a tour through two adult and two pediatric emergency departments in the city of Bucharest. She also had a chance to see the land ambulance and air ambulance systems. During her visit, Dr. Krym had meetings with the Romanian National Committee on Emergency Medicine, the Society of Medicine, the College of Physicians, and

the Emergency Medicine Residency Program Directors. These groups are comprised of emergency medicine physician leaders, including EMS medical directors, from all over the country. The full-day meeting with Emergency Medicine Residency Program Directors was truly an historic event because this was the first time the Program Directors had ever met together. They were very excited to meet with Dr. Krym and share ideas with her and with each other. All of the meetings took place at the historic Ministry of Health building in the centre of Bucharest. Dr. Krym was delighted to see her colleagues from Cluj at the meetings. Dr. Horia Hapca, the Emergency Medicine Chief Resident who came to Sunnybrook for an observership in June 2008, was also present. He remarked to her, “I am so thankful I had the opportunity to come to Sunnybrook last year. It was one of the best experiences of my life. When I am working in the emergency department in Cluj, I remember how things were done at Sunnybrook and use the ideas I learned there in

order to make changes here.”  The overall purpose of the meetings was to develop a national plan for emergency medicine in Romania and it was accomplished. Systemwide, national decisions were made that will move emergency care forward over the next few years.  At the end of her visit, Dr. Arafat invited Dr. Krym to a special ceremony with the mayor to mark the arrival of two new EMS medic vehicles for Bucharest. It was a formal occasion, complete with pipe band and military officials standing at full attention. The two new vehicles are well equipped and represent an important step forward in prehospital care for the capitol. Reflecting on her experience Dr. Krym says, “I was thrilled to assist the Romanian Ministry of Health in helping to advance emergency medicine on a national level in this country. I have seen great progress in the past few years and am happy to be a small part of it.” Laura Bristow works in communications at Sunnybrook Health Sciences Centre.


Hospital News, August 2009

www.hospitalnews.com

Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

25

CritiCall Ontario answers the call for critical care support By Christine Moon

F

or many critical care or specialist physicians in Ontario, a call from CritiCall is nothing out of the ordinary. As a 24/7 telephone consultation and referral resource for hospital-based physicians caring for critically ill patients, CritiCall relies on physicians with expertise in a wide range of specialties to help make sure patients across Ontario have access to the care they need when the stakes are at their highest. And fortunately, many physicians are answering the call. “Critical care is complex and time is always an issue,” says Dr. Avery Nathens, Medical Director for CritiCall Ontario. “CritiCall looks at critical care from a provincewide perspective and then works with that information to get the patient the right level of care, as quickly as possible.” When a physician calls CritiCall for assistance, one of CritiCall’s Call Agents collects relevant patient information and then arranges a telephone consultation with an appropriate specialist. Together, the physicians determine the best course of action for the patient. In some cases, a consultation is enough to provide assurance that the patient can be cared for at the hospital in their community while other times, the patient may need to be referred to another hospital with higher level resources. If a referral is required, CritiCall will search for a hospital with the appropriate resources and expedite the transfer. While relatively simple in theory, the process is actually

quite complex, in part, because of the very fast-paced nature of critical care delivery. To address some of this challenge, CritiCall continues to refine its business processes and in the last year alone, introduced new technology into its Call Centre for telephone communication and call documentation to improve overall service delivery. “The real value of our service comes from the physicians who provide consultations through CritiCall to help their peers right across Ontario,” says Kris Bailey, Executive Director for CritiCall Ontario. “We’re doing our best to use technology to help bring people together as efficiently as possible so we can all do what is best for the patient.” CritiCall is funded by the Ministry of Health and LongTerm Care as a resource for physicians and provides a coordinated and documented approach to critical care. In keeping with this, physicians who use CritiCall for support or to provide support benefit from comprehensive documentation of the patient care process. Call data is compiled into reports available at the hospital, Local Health Integration Network and provincial level that detail each patient case and the types of services required. These data provide valuable information that can be used for health-care planning purposes and resource allocation. From CritiCall’s perspective, this information helps to inform further business refinements that are often tested through pilot projects in partnership with other health-care providers. CritiCall is currently

Surviving the health-care crisis in cancer and cardiac testing Continued from page 7 duced isotopes in trials before the Conservative government pulled the plug. The isotope shortage makes it imperative that this option be evaluated as soon as possible. Canadians expect our healthcare professionals and the government to pull together to ensure patients get the tests and treatment they need in this time of crisis. There is no more appetite for the Conservative government’s inaction, misin-

formation or spin. The federal government must work with the provinces and territories to ensure that Canadians can access medical isotopes so that they can be assured of the best possible care, regardless of where they live in Canada. Dr. Carolyn Bennett is the Health Critic for the Liberal Opposition and Member of Parliament for St. Paul’s, Toronto.

As a Call Agent for CritiCall Ontario, Julie Gordon-Daniels brings physicians together to help care for critically ill or injured patients across Ontario.

working on a number of pilot projects including the use of a dedicated bed registry for mental health resources; the use of remote access to head

CT images to enhance neurosurgical consultations through CritiCall; and, in partnership with the Ontario Telemedicine Network, the potential of virtu-

al critical care to assist patients in rural areas where transferring patients is not always the best option. “Our business is solidly rooted in partnering with others to make the best use of critical care resources,” says Bailey. “In many cases, we have the opportunity to be innovators and try new approaches that bring people and technology together to streamline processes. It’s very exciting and we are able to make progress because physicians and others within the health-care system are willing to collaborate and work together to find solutions to persistent challenges.” For more information about CritiCall Ontario, visit www. criticall.org. Christine Moon is a Senior Public Relations Specialist for CritiCall Ontario.


26

Hospital News, August 2009

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Patient Safety

Keep your eyes on the road By Ryan Sidorchuk

W

hen we were learning how to drive, our instructor, whether it was a family member or a professional, would remind us time and again that if we got ourselves in a sticky situation on the road, keeping our eyes on where we want to go as opposed to the ditch or car into which it appears we are sliding, is the key consideration to come out of the misstep unscathed. The ditch we are collectively sliding towards is the H1N1 virus, now considered a world-wide pandemic by the World Health Organization. We see the confirmed numbers of people with the virus climbing daily throughout Canada. Public health experts throughout the world are warning that the fall will bring stresses on the healthcare system that have only been experienced ‘on paper’, in organizational blueprints for systemic response to an emergency pandemic. We are hearing reports of Health Canada beginning to stockpile mechanical ventilators in the same sentence as there being a shortage of human resources to monitor those ventilators. We are hearing that the schedule to produce an H1N1 vaccine won’t see people being vaccinated until November, and that the supply of that vaccine will necessitate a hierarchy of groups to benefit from that vaccine, with healthcare workers naturally at the top of that list towards ensuring

maximum health system human resources are available for when the seemingly inevitable tide hits society. The above is not meant to be an exercise in fear-mongering, but instead a reminder from an admittedly non-professional ‘driving instructor’ for our health system to keep it’s eyes on the road, on where we want to go versus where circumstances seem to be pulling us. As such, Patients for Patient Safety Canada offers a reminder of the WHO checklist that we published for last month’s Hospital News, and again call upon the health system, patients, and families, to promote the checklist in order to maximize the uptake of a resource that can be instrumental in helping society minimize the damage of the coming collision of extreme stress on the health-care system and society at large. As stated previously, the checklist is adaptable to unique considerations for all jurisdictions, and one should not consider it a stone tablet, but rather a chalkboard containing considerations that will be highly applicable to certain situations, and perhaps less appropriate for others. It is intended to guide and inform versus dictate, and we trust that the information will be found useful for planning considerations now and into the fall. Ryan Sidorchuk is the Communications Co-Chair of Patients For Patient Safety Canada.

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UPON ARRIVAL TO CLINICAL SETTING/ TRIAGE • Direct patient with flu-like symptoms to designated waiting area • Provide instruction and materials to patient on respiratory hygiene/cough etiquette • Put medical/surgical mask on patient if available and tolerable to patient

BEFORE PATIENT TRANSPORT/ TRANSFER • Put medical/surgical mask on patient if available and tolerable to patient

BEFORE ENTERING DESIGNATED AREA (isolation room or cohort) • Put on medical/surgical mask • Clean hands • The above applies to visitors also

BEFORE EVERY PATIENT CONTACT • Put on medical/surgical mask • Clean hands • Put on eye protection, gown and gloves if there is risk of exposure to body fluids/ splashes • Clean and disinfect personal/ dedicated patient equipment between patients • Change gloves (if applicable) and clean hands between patients

IF USING AEROSOLGENERATING PROCEDURES ALSO (e.g. intubation, bronchoscopy, CPR, suction) • Allow entry of essential staff

only • Put on gown • Put on particulate respirator (e.g. EU FFP2, US NIOSHcertified N95) if available • Put on eye protection, and then put on gloves • Perform planned procedure in an adequately ventilated room

BEFORE LEAVING DESIGNATED AREA (isolation room or cohort) • Remove any personal protective equipment (gloves, gown, mask, eye protection) • Dispose of disposable items as per local protocol • Clean hands • Clean and disinfect dedicated patient equipment and personal equipment that has been in contact with patient • Dispose of viral-contaminated waste as clinical waste • The above applies to visitors also

UPON INITIAL ASSESSMENT • Record respiratory rate over one full minute and oxygen saturation if possible • If respiratory rate is high or oxygen saturation is below 90% alert senior care staff for action# • Record history, including flulike symptoms, date of onset, travel, contact with people who have like symptoms, comorbidities • Consider specialized diagnostic tests (e.g. RT-PCR) • Use medical/surgical mask, eye protection, gloves when taking respiratory samples • Label specimen correctly and send as per local regulations with biohazard precautions • Consider alternative or additional diagnoses • Report suspected case to local authority

BEFORE DISCHARGE OF CONFIRMED OR SUSPECTED CASE • Provide instruction and materials to patient/caregiver on respiratory hygiene/cough etiquette • Provide advice on home isolation, infection control and

limiting social contact • Record patient address and telephone number

INITIAL AND ONGOING PATIENT MANAGEMENT • Supportive therapy for new influenza A (H1N1) patient as for any influenza patient including: • Give oxygen to maintain oxygen saturation above 90% or if respiratory rate is elevated (when oxygen saturation monitor not available) • Give paracetamol/acetaminophen if considering an antipyretic for patients less than 18 years old • Give appropriate antibiotic if evidence of secondary bacterial infection (e.g. pneumonia) • Consider alternative or additional diagnoses • Decide on need for antivirals* (oseltamivir or zanamivir), considering contra-indications and drug interactions

BEFORE PATIENT ENTRY TO DESIGNATED AREA (isolation room or cohort) • Post restricted entry and infection control signs • Provide dedicated patient equipment if available • Ensure at least 1 metre (3.3 feet) between patients in cohort area • Ensure local protocol for frequent linen and surface cleaning in place AFTER DISCHARGE • Dispose of or clean and disinfect dedicated patient equipment as per local protocol • Change and launder linen without shaking • Clean surfaces as per local protocol • Dispose of viral-contaminated waste as clinical waste . This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. Source – World Health Organization

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Hospital News, August 2009

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Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

27

From Critical Care Response Team to Critical Care Response System By dr. stuart reynolds

data evaluation and feedback is vital to create a sustainable Critical Care Response System. Over the next year data will be analyzed, and the results provided to each CCRT. Each of these teams will utilize the data to determine areas for improvement; and, identify hospital wards and personnel in need of educational interventions. As well, each hospital will know how it compares to peers with respect to important outcome measurements. This process will guide continued performance improvement and promote a critical care response systems that is focused on patient safety and quality improvement.

T

he foundation of critical care service delivery across Ontario has evolved. This evolution was necessary due to many pressures on the health-care system. The unpredictable surge for hospital resources because of SARS exposed how stressed the system in Ontario had become. We are now faced with the unvarying pressure of a demographic surge. This demographic tsunami has the potential to fracture health-care systems worldwide. The Ontario government has invested in a Critical Care Strategy that focuses on improving access, quality and system integration.One of the leading initiatives under the Critical Care Strategy is critical care response teams (CCRTs). A multidisciplinary group that believed the level of care received by patients should be dependent upon need rather than location within a hospital created the CCRT concept. CCRTs, composed of intensivists, registered nurses and respiratory therapists (RRTs) with specialized training in critical care, are designed to bring acute resuscitation knowledge, skills and resources to patients throughout the hospital. To date Ontario has 27 Adult and 4 Paediatric teams across the province. These innovative teams are providing safe, quality care when and where the patient needs it. CCRTs model a system approach to health care. The teams are multidisciplinary, and move and respond across practice boundries. In order to be effective they rely on the dedicated nurses, RRTs and physicians throughout the hospital. These clinicians identify patients at risk of clinical deterioration and activate the CCRT members for assistance. As well, CCRT members ensure continuity of critical care by following patients discharged from the Intensive Care Unit. To date there has been signficiant interest in the CCRT and Rapid Response Team phenomenon. The literature, not surprisingly, does suggest that a CCRT must be utilized in order to be effective. Therefore during the first years of CCRT implementation; the focus has been to ensure the CCRT’s are utilized.

Toronto General Hospital Criticval Care Response Team members: From left: Liz Romano, Denise Morris, Linda McCaughey, Penny Damilitis and Stu Reynolds. Since implementation, it has been the privilege for CCRT members in Ontario to assist in the care of 152 267 patients. To reduce the number of ICU readmissions the vast majority of these are patients were identified prior to discharge from ICU’s and followed for a minimum of 48 hours. Clinician colleagues throughout the hospital utilizing specified calling criteria or their clinical judgement identified the remaining referrals. Over the last six months across the 27 Adult CCRT hospitals, there has been on average over 40 new consults/1000 hospital admissions. This referral rate, in this time period, is in excess of those established in similar centers around the world. These activities have led to important improvements in patient safety and outcomes. For example, Toronto General Hospital, since the implementation of CCRT, has been able to identify and respond to patients earlier in the course of their acute illness. This has resulted in a near 40 per cent reduction in ICU mortality and a greater than 50 per cent reduction in the number of patients being admitted to the intensive care unit after cardiac arrest. Benchmarking is an important concept in quality and performance improvement. Just as utilization was identified as the most important first step during the implemention of a Critical Care Response Team;

Dr. Stuart F Reynolds is a Physician Advisor - Critical Care Response Teams and Critical Care Physician at Toronto General Hospital.


28

Hospital News, August 2009

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Focus: Emergency Services/Critical Care/Trauma/Emergency Preparedness

The emergency door flood gates: Is that a bottleneck in your patient flow? By Jennifer HallidayDinon

T

he emergency room (ER) represents the largest portal of entry into hospitals, accounting for 65 per cent of admissions to acute care beds each year - The Canadian Institute for Health Information (CIHI) identified in their 2007 report that 68 per cent of patients admitted in the ER required acute care medical beds. The ER represents a key area that operates at a fast-pace with high turnover of patients and can respond to, at any given time to patients requiring priority or emergent care. Once a patient has been admitted into the hospital system through this portal, a bottleneck can occur quickly, thereby impeding its staff member’s abilities to attend to its emergent patients. The need for a timely transfer of patients to an inpatient care unit must be coordinated for a safe, seamless and transparent process that involves each unit leader. Managing the flow of patients into, and across organizations efficiently and effectively requires a consistent, flexible and integrated plan that is utilized and equally well understood across the organization. A supply chain management approach facilitates the identification of risk, redundancy and bottlenecks within the flow of patients and information needed for the safe transfer of a patient’s care. Paired with an intuitive software program or Enterprise Resource Planning (ERP) program will provide a useful dashboard to quickly identify and monitor ready-fordischarge patients (RFD) to determine the appropriate use of acute care beds and to identify appropriate patients for immediate discharge during a pandemic or crisis. The current research literature largely reflects our US counterparts. Canadian research on effective bed utilization and its effect on patient flow is largely in its infancy. In private sector business organizations, it is not uncommon to find supply chain management for not only materials, but services and information as a source of competitive strength, providing a distinction among saturated markets. We are now in a time where Ontario hospitals must also identify gaps in how patients access timely acute care services and links within the chain that are risky or inefficient. An organization

is only as strong as its weakest link. Implementing such a system will result in improved patient and staff satisfaction and patients that receive the right care, by the right provider, in the right bed, at the right time. Both bed capacity and human resources are critical - nurses and physicians have a direct impact on an organization’s ability to meet patient needs in a timely and effective manner. Confidential information exchange must be accurate and timely, prior to taking over patient care to effectively provide quality care in a safe environment. Information management is a critical component to patient care safety. Transparency and communication with stakeholders is important to establish, maintain, and develop relationships. As Ontario hospitals transition to improve transparency, improved bi-directional communication must take place in order to improve the public’s awareness about the organization when entering the hospital system. Ontario hospitals have already begun to report ER wait times on hospital websites. Data from the beginning of 2009 indicated an average wait time in ER ranging from 5-13.6 hours, with a Ministry set target of 8 hours. This is an excellent first step in the overall patient

flow management process and can be utilized as one indicator for the patient care experience and can set the stage for further data and knowledge management. While many hospitals have their own form of a quick fix or band-aid solution, an integrated software program can provide real-time data, would reflect the organization’s overall strategy and its values with the ability to predict and respond to patient volumes vs. a reactionary nature. There are both variable and invariable factors that must be considered when considering how patient care needs are met and how this may represent a barrier to accessibility of services. Variability in admissions can be forecasted to a large degree considering historical data on seasonality, changes in healthcare services in the community (such as the closure of walk-in clinics or retirement of family physicians), outbreaks in alternate care facilities, and media, particularly on communicable diseases. Planned admissions include surgeries and repatriations. There is often a disconnect with planned surgeries in terms of days of the week and availability of beds and staff, largely related to a surgeon’s booked OR times, and advanced bookings. Other factors for consideration in planning are the

percentage of alternate level of care (ALC) beds as part of an organization’s acute care beds, which represent bottlenecks outside of the hospital environment. Across Ontario, nursing shortages and disengaged staff lead to a high turnover and sick time, reducing the organization’s ability to respond to patient care levels effectively and costly overtime demands resulting in higher operational costs and increased risk to the safety of both staff and patients. Nursing staff are at the forefront of meeting these increased workload demands, mitigating increased infection control risks, increasingly acute patients, and stringent documentation practices needed for the protection of their own licensed practice, communication across the multidisciplinary team and organizational requirements. Risks include surgical cancellations, the inability to accommodate out-of-county patients in other facilities who are away from family and friends, patients not receiving level of expertise they would if in the right bed at the right time, patient anxiety related to not knowing when a bed will be available, sharing a patient room with the opposite gender due to cohortation to accommodate as many patients as possible, an absence of a quiet and restorative environment due to being held in ER, patients experiencing delays in ER due to lack of room availability and staff resources being utilized with held patients awaiting transfer. CritiCall’s services are reserved for exceptional and complex patient cases when the nearest hospitals do not have the resources to meet the patient’s health-care needs. Patients may be transferred to facilities outside the province or country resulting in significant costs to the health-care system and the time needed to find and transport such patients to these organizations places them at a higher risk for undesirable outcomes such as discomfort, additional worry, and potentially higher mortality and increased costs. Key hospital practices that can reduce risk, contribute to staff engagement, and accommodate a smoother patient flow into hospitals: • Policies and procedures that are integrated into the overall strategy of the organization, engaging all staff and physicians • Incorporate patient communication tools (at admission, signage in ER to identify tran-

sitions to and from hospital admission) • Bringing in a Patient Flow Specialist to specifically manage the portfolio of Central Registry department and bed facilitator to identify areas for improvement within the supply chain and facilitate communication across the organization and with key external partners in alignment with the values of the organization • Identify targets, set metrics and report them. Examples include established targets for discharges each day or estimated length of stays based on best practices or CIHI. Include key findings in ER wait time reports to provide informative information to stakeholders • Acknowledge increased ARO status of patients and create plans to minimize exposure to other patients through a planned cohortation of patients and effective infection control practices such as hand hygiene, patient and family education for isolation needs and practices • Create a community of practice across regions to establish processes and practices and benchmarks to develop strong infrastructure Smoother flow results in better patient care, as patients receive the right care in the right bed at the right time. The ER department will be able to respond and function as it was designed - to focus on treating the episodic events of the patient in their department and releasing those that do not require admission. Removing redundancy, delays and other activities that do not create value, hospitals can improve their ability for patients to access care and increase patient and staff satisfaction through improving the patient care experience. Aligning with the Lean philosophy, an organization that can predict an event, can prevent it. Fluctuating volumes of patients moving into an organization does not need to create gaps or variability in the patient care experience. Now that’s money well-spent. Jennifer Halliday-Dinon, MBA (Candidate 2009), GDM, BScN, RN currently works as an Analyst in a community hospital and has experience in the management of patient flow, mitigating risk, and allocating appropriate resource utilization. She can be reached at jhalliday99@ yahoo.com


Hospital News, August 2009

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Financial Health Matters

Financial Health: Urban myths debunked By Brian singer

I

would like to look at some “urban myths” that are out there regarding stocks and bonds and look at what history has to say versus what is being marketed in the financial press. There are those stock junkies out there that hold on to several urban myths that I want to shed some light on. Stocks always go up. They are punctuated by some years where large losses occur. Stocks are supposed to deliver superior and steady long term returns versus Bonds. And Equities are supposed to do be in Bull markets more than in Bear markets - In fact there have been long periods of disappointment in the stock market, interrupted by some great periods of gains. Why do you hear the line “the lost decade” regarding stock market returns? Starting in 1997 and through 2008, stocks have produced negative returns for just over a decade. Stocks historically outperform bonds and by at least 5 per cent (also known as the

HOSPITAL NEWS MARKETPLACE CLASSIFIEDS See your classified ad here – Get a classified ad with 3 lines of text to list your key products, services and contact information. A great value for space for small to medium businesses. To advertise, please contact advertising@hospitalnews.com or phone 416-781-5516 ext.2 CONFERENCES: A Day In Psychiatry: Oct 9 Stratford ON Dr Mike Slade, Dr Gabor Mate, Dr Keith Jarvie 519-272-8210 ext 2571 EYEWEAR: College Optical at Sick Kids Hospital, All hospital staff – ask about our 25% discount. (416) 813-7654 collegeoppticians.com FLOWERS & GIFTS: For all your Gift Basket and Gift giving needs for any occasion in the GTA. Highland Hill Creative. Call 416.256.5221 or visit www.hhcreativegifts.ca. FOOTWEAR: Foot Solutions, Quality orthopedic shoes, Custom made foot orthotics. 905770-5153 richmondhill@footsolutions. com FUNERAL SERVICES Dixon Garland Funeral Home We offer kind, compassionate and professional care 905-294-2030 Dixongarland.com

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risk premium) - Studies done by fund manager Dr. Rob Arnott who is also editor of the Journal of Indexes, show that had you simply bought a 20 year US Treasury bond, reinvested the interest and then every year sell the previous Treasury and buy the newer

media would have you believe. Two per cent is not a great margin, given the risk you assume as a shareholder in a traded company. A diversified Portfolio will protect you when one asset class underperforms and will weather the storms - According

500, the SCI Emerging markets index, the Barclays Aggregate Bond Inex etc. Last September 2008 after the collapse of Lehman Brothers and when the corporate bond market sank, none of the asset classes gave back any profitable returns. This has never happened

Instead of investing according to theorems and studies, invest according to your goals and objectives—these you know are correct since they are your own wants and desires.

20 year Treasury, you would have beat the passive S&P 500 investor. And that is from 1969 to 2008, over 40 years. Going back to 207 years of data in the US shows that stocks beat bonds by 2.5 per cent and not by 5 per cent as most in the

to Dr. Arnott, “Diversification is overrated, especially when we need it most.” So what happened in September and October of last year? In Dr. Arnott’s asset allocation work, they model the performance of 16 asset classes such as S&P

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before. Then October happened and again not one asset class showed any rise in price. But isn’t one asset class supossed to Zig when the other Zags? This is true, in normal situations. But last Fall was not one of those normal periods.

Unlike stocks, especially non-dividend paying stocks, bonds still offer the investor a steady stream of coupon interest payments. This cash flow makes a huge difference in portfolio performance and as long as the bonds are good quality, principal will be returned. Can we say that with certainty for our stocks which are way underwater? Lesson to be learned: Don’t believe all the hype out there. Instead of investing according to theorems and studies, invest according to your goals and objectives—these you know are correct since they are your own wants and desires. Figure out what you want your money to be used for in the future, and how much you will need. If you can meet those goals, even if your neighbour’s portfolio has done better a certain year, you still will be satisfied. Getting back to basics is often the best way to go forward again.

Because some wishes can’t wait for someday.

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Hospital News, August 2009

Careers

View career ads at www.hospitalnews.com

Clinical Leader/Manager - Obstetrics & Gynecology St. Michael’s Hospital is a Catholic academic healthcare provider, fully affiliated with the University of Toronto and committed to innovative patient care, teaching and research. St. Michael’s Hospital is an equal opportunity employer.

Seeking a results-oriented individual to: • lead a multi-disciplinary team in advancing evidenced based practices • manage high quality inpatient and ambulatory care delivery including a new state-of-the-art women’s health care clinic • be part of a values driven organization

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BILINGUAL RN Innomar Strategies is a leading service provider to pharmaceutical and biotech manufacturers, and the healthcare community. We are hiring for Bilingual (French/English) RN’s for a Caseworker role.

Innomar offers: Flexible Hours, Competitive Salaries & Benefits, Opportunities for Growth and Advancement, and an Energetic, Dynamic Working Environment! For more information visit the Careers Section of our website: www.innomar-strategies.com Please send resumes to careers@innomar-strategies.com or fax to 905-681-9598 Thank you for your interest in Innomar Strategies. We are an equal opportunity employer.

MANAGER, Nursing Services

Have you considered becoming a Foster Parent? As a Treatment Foster Parent, you can expect to: UÊ Benefit from working full time from home UÊ Employ your knowledge and expertise UÊ Observe positive changes in a child UÊ Connect as a team with other foster parents UÊ Prevent children from being institutionalized UÊ Earn up to $1800 per child per month UÊ Benefit from extensive support, including social workers, youth workers and ongoing training Previous experience in working with challenging youth preferred; however, all inquiries are welcome. For more information contact Alex Blake: Office: 905-475-1630 ext. 224 E-mail: alexmaplestar@bellnet.ca Apply: www.maplestarservices.com

We are a large busy family practice medical clinic in Toronto, located on the subway. Illness has left us with a need to find a Manager, Nursing Services. This is a full-time position responsible for leading our dynamic nursing team which supports both our family physicians and our specialists. RN qualification and good standing in the College of Nurses of Ontario plus relevant experience is essential. This role will be a key player in the redesign of our nursing department envisioned as part of our move to new facilities in 2009. We offer competitive salary and benefits. Please fax your resume to Human Resources at 416-461-2710 or email to amcrecruitment@rogers.com

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Infection Control Professional Looking for an experienced dynamic health care professional to: St. Michael’s Hospital is a Catholic academic healthcare provider, fully affiliated with the University of Toronto and committed to innovative patient care, teaching and research. St. Michael’s Hospital is an equal opportunity employer.

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Hospital News, August 2009

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2009, August - Hospital News