Dalhousie University Department of Critical Care Annual Report
2017-2018
Snapshot
Leadership Message
MISSION
SERVING DIVERSE CARE NEEDS
Accountability and excellence in medicine
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The Multi-Organ Transplant Program
In the Department of Critical Care, we provide exemplary, compassionate and supportive care to critically ill patients, using a multidisciplinary approach that is based on evidence and updated regularly to reflect new research discoveries and improved best practices.
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General Surgery
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Thoracic Surgery
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Ear-Nose-Throat Surgery
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Urological Surgery
W H AT W E D O
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Gynecological Oncology
Critical Care adult
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Oral Maxillofacial Surgeries
Critical Care pediatric
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In-patient Dialysis Unit
Provincial Critical Care Program
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Bone Marrow Transplant Unit
Organ and Tissue Donation
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Hematology/Oncology
Medical Education
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Gastrointestinal Medicine
Research
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General Medicine
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Neurosurgery
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Orthopedics
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Trauma
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Acute General Surgery
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Plastic Surgery (including severely injured burn patients)
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General Internal Medicine
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Respirology
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Neurology
WHERE WE DO IT Halifax Infirmary, QEII Victoria General, QEII Dartmouth General Hospital IWK Health Care Centre
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It has been my privilege to serve as the Interim Department Head for the Department of Critical Care for the past fifteen months. I want to thank all Department members for their support; it’s been a pleasure to serve in this role. We have accomplished a lot in the past year. We finalized the governance structure and the practice plan which is the legal and administrative backbone of the Department. Simultaneously, we have supported the planning and execution of a health services restructuring process, not only for the Central Zone but province wide. These planning sessions were a main component of my initial work as Department Head, and I am hopeful that the future will bring a better work environment for all of us. We have already witnessed the groundbreaking with the Dartmouth General construction, a planned expansion that will provide new space for the Dartmouth ICU. For the first time in over a decade, we have recruited to our full complement for both our pediatric and adult groups. This helps us more reasonably share our clinical and academic workload. We have also successfully advocated for an additional full-time intensivist at the Dartmouth General. The search is underway to fill this position. Our successful accreditation was another milestone for the Department and the Nova Scotia Health Authority. I was proud to see the critical care aspects, especially in the Central Zone, receive excellent reviews. The accreditors singled out the Mobilization Project, the Organ Donation Program and the surgical pause initiative as excellent examples of patient-centered care. My thanks goes to our quality team Drs. Sarah McMullen, Volker Eichhorn and Quality Lead Karen Webb-Anderson for leading us through a smooth and successful accreditation process and to all those involved in the initiatives and programs for your leadership, time and energy. On the education front, the amalgamation of the two academic groups (adult and pediatric) better positioned us to deliver our education responsibilities. We continue to have strong interest in our fellowship program, as evident by the number of applicants we’ve had the last two years. This is a direct result of our dedicated Fellowship Program Director, Dr. Babar Haroon, and the Department members who offer exemplary teaching. My thanks also go to Dr. Edmund Tan for establishing the ultrasound training
program which will move us forward in providing Ultrasound teaching for our students, residents and fellows, along with training and quality assurance for all ICU staff. Our research efforts are now gaining new momentum, as Research Chair, Dr. Osama Loubani, leads the Department’s research mandate. With a new structure to support the group, including integrating the pediatric group, I am confident we will increase our research output and establish ourselves as a strong research partner. We were sad to say goodbye to two longstanding members, Dr. Bill Gallacher and Dr. Rick Hall, as they retire from clinical service in the ICU. They have both made important contributions to our Department as outstanding clinicians who have dedicated so much time and energy into moving our education and research agendas forward. On behalf of the Department, I wish them all the best for their future endeavours, as I believe that both of them will find something else to keep them occupied. Finally, I would like to extend a heartfelt welcome to our new Department Head Dr. Tony O’Leary who is joining us from Nottingham, England. I wish him all the best in the new position and hope that we will continue to grow as a group under his leadership.
Dr. Tobias Witter Interim Department Head Department of Critical Care, Dalhousie University (January 2017 - March 2018) 2 0 1 7 - 2 0 1 8
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Who We Are & What We Do
RESEARCH
PATIENT CARE
38
2,325
ICU beds
(up 2%)
admissions
AWARD WINNING TEAM
$109,025
7 researchers with 20%+ protected time
grant & industry funding (up 3%)
4.4
3.9
average stay in adult ICU
average stay in pediatric ICU
32
9
publications
(down 4%)
(up 17%)
(2017 calendar year)
invited lectures
WORD ON THE WARD
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[I value] our collaborative approach to providing excellent patient care 24/7 days a week, all team members have a voice and most importantly are heard! – Lesley Bishop, URN
9 major awards recognizing Department members in 2017
I am so very proud of how our entire team pull together to ensure that patients and their families receive our top-notch care. Our team goes beyond doctors and nurses and encompasses all members of the inter-professional team, and this makes a huge difference for patients and their families as well as for our staff. Staff know that they can rely on each other’s strengths to provide the best possible care every time. – Cynthia Isenor, Director, Policy and Planning, Provincial Critical Care Program
(see list on page 10 )
FEEDBACK
Families give ICU Care Team high scores* (Scale 1-5) MEDICAL EDUCATION - 157 Learners Postgraduate Medical Education
67 internal medicine residents (300 weeks) 20 anesthesia residents (108 weeks) 9 emerg medicine residents (56 weeks) 23 surgery residents (166 weeks)
Undergraduate Medical Education
24
Med 3 students
( 66 weeks in the ICUs & 24 weeks in the OR with anesthesia )
14
Med 4 students
( 34 weeks in the ICU )
Overall satisfaction
4.5
Courtesy, respective, compassion
4.6
Ability to assess & treat patient *For the 3A and 5.2 ICU at QEII
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4.4
Seeing and leaving behind happy patients and families makes me proud. – Dr. Volker Eichhorn
It can be as simple as watching for changes in vital signs, delivering a first dose antibiotic quickly, or mobilizing to the side of the bed for the first time. It can also be offering a shoulder and a box of Kleenex to a family in distress. All of these simple yet important steps can positively affect outcomes for both the patient and their family. – Pam Hughes, RN
My brother’s personal nurses were beyond caring for his comfort. Their attention and attitude towards me were not necessary, but they showed genuine concern and empathy for my feelings. – Patient Family Member
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Leadership INTRODUCING TONY O’LEARY Dr. Tony O’Leary began his five-year appointment as Department Head & Chief on March 2, 2018. Dr. O'Leary comes to the Department most recently serving as Clinical Chair and National Advisor for Anesthesia, Critical Care and Resuscitation for Spire Healthcare in Nottingham, United Kingdom. In this role, he helped create robust governance and clinical processes for the new private hospital. The position evolved from Dr. O’Leary lending his expertise through the hospital’s construction. Previously, he served as a consultant in critical care and anesthesia at Nottingham University Hospitals NHS Trust, a large tertiary referral hospital with 68 critical care beds. There he was also Head of Critical Care for three years, where among other accomplishments, he established the Department’s strong foundation in clinical governance and education. Dr. O'Leary received his medical degree from the University of Dundee in Scotland and his Masters in Healthcare leadership with the NHS Leadership Academic and the University of Birmingham. Following his training and working in general internal medicine and gastroenterology for six years, he completed his Fellowship in anesthesia and critical care medicine with the Royal College of Anaesthetics, London (FRCA) and a Fellowship of the Faculty of Intensive Care Medicine (FICM). In 2017, the Royal College of Physicians (Edinburgh) accepted Dr. O'Leary as Fellow in recognition of his teaching and managerial contributions [FRCP (Edin)]. Dr. O'Leary has a passion for medical education and medical leadership at both the undergraduate and postgraduate levels with a focus on the use of simulation in multidisciplinary team settings. He has taught critical care and simulation courses locally, nationally and internationally. 5
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2017-2018 Highlights LEADERSHIP TEAM Dr. Tobias Witter
Acting Department Head (term ended March 2018)
Dr. Tony O’Leary
Department Head (effective March 2018)
Dr. Babar Haroon
Program Director
Dr. Osama Loubani
Research Chair
Dr. Jorin LindenSmith ICU Site Chief, Dartmouth General Dr. Gavin Morrison
Chief of Pediatric Critical Care, IWK Health Care Centre
Dr. Janice Chisholm
QEII Site Chief, Critical Care
Dr. Stephen Beed
Medical Advisor, Provincial Organ and Tissue Donation Program
Dr. Ward Patrick
Senior Medical Director, Provincial Critical Care Program
Dr. Sarah McMullen
Co-Chair, Critical Care Quality & Patient Safety Committee
Dr. Volker Eichhorn
Co-Chair, Critical Care Quality & Patient Safety Committee
3 Wishes Project de-medicalizes death and dying In 2018, the QEII ICUs adopted the 3 Wishes Project. The project aims to de-medicalize death and dying, humanize the austere ICU environment, and enable spirituality (where desired) during the dying process. It celebrates the lives of those lost and supports those left behind in grief, by carrying out at least three simple wishes for dying patients. This is a low-cost, low-tech project, where actions and gestures speak volumes. Drs. Jennifer Hancock, Sarah McMullen and Marko Balan spearheaded the program introduction, met with the enthusiasm and support of dedicated and enthusiastic nursing staff. The Program was originally designed in an ICU in Hamilton, Ontario by Dr. Deborah Cook, and has expanded to Toronto, British Columbia and now Nova Scotia.
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8 per cent reduction in complications, and, 10 per cent reduction in mortality.
The early mobilization program is now a standard of practice within the ICUs at the QEII. The team has presented as a multitude of local, provincial and national meeting and conference and looks forward to supporting other ICUs across the province to adopt the practice.
Pilot study shows early mobilization improves care The Department’s flagship early mobilization pilot program supports patients to get moving as soon as safely possible. The program, led by staff nurses Marlene Ash and Elinor Kelly, with Dr. Rob Green providing medical leadership, progresses patients through a range of activities including in-bed exercises to mobilization about the ICU. While in the past it was believed bed rest was essential to allow more serious illnesses to heal, today’s evidence shows the value of early mobility. The change in practice required a shift in thinking and a real integration of the full care team, including relying on the strengths and expertise of physiotherapists, now a member of the seven-day-a-week team. Literature shows early mobility improves long-term outcomes with the patient’s critical illness, including reducing ICU delirium and its negative sequel. Following its introduction in 2014, outcomes demonstrate the program’s value, including a profound impact of reducing delirium by 25 per cent. In addition, using the Trauma Nova Scotia database, the team has been able to assess the program’s impact by comparing patients before and after the introduction of the program. Results show: • •
Fewer total ICU days, Fewer days of ventilation (average one day less)
Pediatric ICU extends Outreach Team to ambulatory care The Pediatric Critical Care Outreach Team has been extended to support ambulatory care services. This team can be activated by any health-care provider concerned for a patient’s deteriorating health, yet not requiring admission to the PICU. The program helps with early detection of a patient requiring a higher level of care and offers new and increased support outside the PICU session, it also reduces the number of unplanned admissions and educates staff.
481 PICU ADMISSIONS (up 27% in five years) 2 0 1 7 - 2 0 1 8
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2017-2018 Highlights (Cont’d.) Dartmouth General Hospital ICU team prepares for new space and new intensivist The Dartmouth General Critical Care team, led by Site Chief Dr. Jorin LindenSmith, will have an additional full-time intensivist added to its complement. A search to fill the new approved position is underway. The team continues to support the anticipated hospital expansion which will see the creation of a modern ICU space. The new space will see a relocation of the current eight-bed ICU/CCU and the creation of new six-bed Intermediate Medical Care Unit. The Dartmouth General ICU group continues to train undergraduate and postgraduate medical learners and holds quarterly Journal Clubs, in partnership with Internal Medicine. ICU cases are also presented at the monthly Internal Medicine Case rounds.
With a reputation as the national leader in organ donation, the program has witnessed a slight dip in its donation rates (17 donors/million). The group is now reviving its strategic plan and restructuring the program. The changes will be modelled on changes made in provinces like Ontario and British Columbia who are experiencing significant increases in organ donations. The program’s restructure, led by Program Manager Janet Gallant, includes developing a centralized model, increasing organ donor education and hiring more organ donor coordinators around the province (of which two have already been hired). With the planned investment in system change, Nova Scotia is once again expected to be a national leader in organ donation. Accreditation Leadership team applauds Critical Care The Quality and Patient Safety Committee (QAPS) was the driving force behind the Department’s role in the Nova Scotia Health Authorities successful accreditation. When the positive accreditation status was shared, three of the Department of Critical Care programs were singled out as excellent examples of patient-centric care. The programs were: early mobilization (led by Dr. Rob Green), the provincial organ donation program (led by Dr. Stephen Beed and program manager Janet Gallant) and the urgent admission pause program which has improved the transfer of care process (led by Dr. Tobias Witter). The programs are a success for not only what they do, but for how they do it. Each program requires a fully integrated team where colleagues communicate well and trust one another. Congratulations to the dedicated teams for pursuing their vision to improve patient care and as a result raising the bar for new models of patient-centric care.
Provincial program embarks on restructure to revitalize organ donations Normalizing organ donation continues to be a top priority for the provincial Legacy for Life Nova Scotia Organ and Tissue Donation Program. The program’s Medical Advisor is Department of Critical Care physician, Dr. Stephen Beed. 7
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Provincial Critical Care Program creates new database to support province-wide planning Each year Nova Scotia spends in excess of $50 million on critical care services, making it imperative to be accountable and efficient in how it delivers quality critical care across the province.
The Department’s, Dr. Ward Patrick, serves as the Provincial Critical Care Program’s Senior Medical Director. Dr. Patrick and his team are tasked with developing a province-wide critical care program. This year the program struck a Critical Care Provincial Council which has interprofessional representation from all zones and critical care environments in Nova Scotia and includes two members of the public. One of the group’s first tasks was to design, build and implement a critical care database. The database will support evidence-informed decision making and guide changes for a high-functioning and sustainable critical care service in the province. This database, first of its kind for critical care in Nova Scotia, will capture the data at all critical care sites in the province. The database is expected to have sufficient data to support decision making within the next 12 to 18 months. Special thanks to the Critical Care Database Committee, led by Dr. Osama Loubani, Dorothy MacAskill and Cynthia Isenor. The Council is also working to standardize care by developing standardized order sets for clinicians looking after critically ill patients across the province. To date, different approaches to critical care are offered based on the location and physician. Working with Think Research, Dr. Volker Eichhorn and Cynthia Isenor (the new Director of Policy and Planning for the Provincial Critical Care Program) are tasked with leading this project. The group plans to develop 10 order sets in the first year. Best Wishes to Sharon Stevens The Program says goodbye to Senior Director, Sharon Stevens who retires in September 2018. Sharon has made an immense contribution in bringing the program to life, including building strong connections across the province that will exist long after her departure. Welcome to Ms. Cynthia Isenor, who will capably take the helm as the Program’s Senior Director.
Department to participate in eight clinical trials Research Chair, Dr. Osama Loubani, along with research coordinator, Ms. Diana Gillis, are on a mission to grow the Department’s research activity. Since Ms. Gillis joined the team in March 2018, the Department has participated in four multi-centre national and international clinical trials and plan to begin another four at the QEII. The trials examine diverse topics from the role of probiotics in preventing infection, to the sensitivity of new imaging techniques in diagnosing brain death, to the search for new blood tests to help predict outcomes in brain injury, and an examination of whether prolonged antibiotic administration is any better at treating infection than shorter courses. Participation in these studies gives Department members and patients the opportunity to participate in cutting-edge research that may well become tomorrow's standard of care. The research contributions of the Pediatric ICU colleagues, who officially joined the Department last year, are welcomed and appreciated. This small group of four clinicians demonstrate impressive research productivity. They were published eight times in the past year and generated $86,650 in external research funding – 79 per cent of the Department’s overall funding. 2 0 1 7 - 2 0 1 8
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2017-2018 Highlights (Cont’d.)
Recognition
The research group is also increasing its focus on supporting Department members who lead research, without protected time. This includes supporting a member-led (Dr. Jennifer Hancock) survey seeking to understand burnout in the ICUs and contributing to a clinical trial that examines the best method to prevent low oxygen levels in patients about to be put on a ventilator for breathing support. The goal is to encourage all members to pursue interesting questions that they may not otherwise feel capable of pursuing.
serving a niche role in the provision of critical care in Nova Scotia. Dr. Laurel Murphy (2017) offers her expertise in neuro-critical care, and Dr. Edmund Tan (2017) has spearheaded the development of the Department’s Point of Care Ultrasound program. Meanwhile, Dr. Kevin Klassen (2018) will provide acute care in Sydney, Cape Breton and Dr. Jack Rasmussen (2018) will stay in Halifax focused on caring for burn victims, marrying his interest in burn care with his plastic surgery background and acute care training.
AWARD WINNING TEAM
Going forward, researchers will continue do ground-breaking research from across the globe, while the Department encourages all members to pursue their research interests.
For the upcoming academic year, the Department welcomed three new trainees – all from Atlantic Canada: Dr. Iain Areneau who aspires to practice in Truro, NS, Dr. Steve Walsh in Prince Edward Island and Dr. Miles Clayden in St. John’s, Newfoundland and Labrador.
The Department of Critical Care is privileged to work among a group of talented professionals. Congratulations to the following colleagues who were honoured this past year for their clinical care, teaching and/or research excellence.
AMS Donald Richards Wilson Award for CanMeds Integration – Royal College of Physicians and Surgeons Academic Innovation Award – Dalhousie Center for Learning and Teaching
Dr. Stephen Beed
Dr. Babar Haroon
Distinguished Service Award, Doctors Nova Scotia
Silver Shovel Award: Most Influential Educator over Three Years – Dalhousie Faculty of Medicine
Mentor of the Year – Royal College of Physicians and Surgeons, Region 5 Dr. David Brake
The Department trained its first visa trainee, Dr. Abdulehah Ibrahim Akkam, who completed a one-year critical care fellowship and welcomes its second visa trainee, Dr. Mujtaba Al Khalaf who will complete two full years of training.
Dr. Janice Chisholm
Dr. Laurel Murphy Rising Star Award – Canadian Association of Emergency Physicians
Rural Physician of the Year – Doctors Nova Scotia Dr. Rick Hall Gold-Headed Cane Award – College of Physicians and Surgeons Nova Scotia Gold Medal Recipient – Canadian Anesthesiologists’ Society
Education program sees trainees choose Nova Scotia as the place to practice The Department’s education efforts, capably led by Dr. Babar Haroon, have witnessed impressive retention rates in recent years. All four graduates of the subspecialty critical care training have chosen Nova Scotia as their place to practice in 2017 and 2018. This level of retention validates the quality of not only the education program but of the positive work environment fostered by the Department. Each of the newly trained physicians is now 9
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