Hospital News February 2019

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Inside: Long-term Care | Evidence Matters | Safe Medication | Nursing Pulse | Careers

February 2019 Edition

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NEWS

Collaborative and patient-centred design By Mariela Castro mbracing innovation has always been one of the fundamental pillars of West Park Healthcare Centre. At its recent “turning of the soil” ground-breaking event, the hospital celebrated a major milestone towards transforming its 108-year old campus into a world-class, integrated campus of care, with a new hospital at its core. But the Centre is breaking ground in other areas, too. Before – and after – the new hospital becomes reality, it is taking measures to ensure the new building will be optimally designed to help patients get their lives back. And it is doing so via the Post Occupancy Evaluation (POE), an innovative, comprehensive initiative to improve healthcare design.

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HEALTHCARE DESIGN FOR THE FUTURE The POE will evaluate how the new hospital will affect employees, patients and their families, and operational efficiencies, for six significant design elements: Outdoor/Green Spaces (the connection to nature); Family Zones; Integrated Bedside Terminals; Congregate Dining; Team Substations; and Decentralized Patient Registration. Planned for 2018 through to 2025, the study will result in a comprehensive report for the Ministry of Health and Long-Term Care (MOHLTC), contributions to scientific literature, and the publication of quantitative and qualitative results manuscripts, a methodology paper, and a “lessons learned” report. While by definition the POE is “the process of evaluating buildings in a systematic and rigorous manner after they have been built and occupied for some timep;”, for West Park, the POE extends beyond evaluating the new hospital after the move-in date. The study of the hospital’s design, use and operating conditions is being conducted pre- and post-occupancy. “Healthcare redevelopment projects within Ontario now require a post-oc-

Some of the cross-functional team, pictured in front of the new West Park hospital display. cupancy evaluation be conducted. By analyzing evidence gathered from research, these evaluations will help the industry and the hospital understand what design elements work best, and in what context. As we move forward with healthcare developments, it is crucial that we understand the full impact of how designs affect outcomes,” explains Martha Harvey, Senior Project Manager, Clinical Integration at West Park.

EVIDENCEBASED DESIGN As part of an evidence-based design process, robust feedback is being collected from stakeholders on how the hospital supports the organization and its staff, volunteers, patients and patient friends and family. “The POE is a notable example of West Park’s focus on applying stringent scientific rigour to its innovation projects,” adds Jan Walker, VP-Strategy, Innovation and CIO, and head of the Centre’s cutting-edge Research and Innovation department. “POE data is gathered through rigorous survey methodology including questionnaires, focus groups,

interviews, and observational monitoring. It supports the goals of the new hospital project, and aligns with the Health Quality Ontario framework, Senior Friendly Design and the WELL Building Standard. It also takes into consideration MOHLTC planning principles, and is judiciously reviewed and approved by the Joint Research and Ethics Board.”

PATIENT AND FAMILY COLLABORATION Patient and family involvement is also key. In keeping with the Centre’s focus on patient and family-centered care, the Patient Experience Department plays a critical role in ensuring the voices of each of West Park’s varied populations are heard. Coordinator Sarah Benn-Orava is heavily involved in recruiting patients and their family members to solicit their input. “Our patients are thrilled to be able to share their West Park experience,” she says. “Patient and family engagement is at the foundation of West Park culture. Documenting their insights and feedback is tremendously meaningful for each of the six POE projects.”

Shelley Ditty, VP of Campus Development and Support Services, concurs. “Hospital design is an integral part of the patient and family experience, and we want to ensure the new building design contributes to better outcomes for our patients. Ultimately, great design aims to bring about a great patient and family experience – bringing services, programming and staff expertise more directly to the patient, better integrating research with patient care, and fostering collaboration between departments,” Ditty says. “The POE will greatly contribute to strategic planning and decision-making for campus development.”

A BOLD FUTURE AHEAD Scheduled to open in 2023, the new West Park hospital represents the future of healthcare. By integrating leading-edge, evidence-based architectural design into its campus, West Park is poised to help patients faced with life-changing health challenges reclaim their lives and realize their H potential, for decades to come. ■

Mariela Castro is Research Assistant - POE, Campus Development, West Park Healthcare Centre. 2 HOSPITAL NEWS FEBRUARY 2019

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Contents February 2019 Edition

IN THIS ISSUE:

New technology makes testing faster

5 ▲ Cover story: Infection prevention is in your hands

22

▲ Healthcare infrastructure projects in Ontario

12 ▲ Creating a safer, greener and cleaner MSH

COLUMNS Guest Editorial .................4

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In brief .............................7 Doctors without Borders 14

▲ Infection control supplement

17

Nursing pulse ................16 Evidence matters ...........32 Long-term care ...............36 Safe medication ............46

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▲ Designing for cognitive well-being

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New life-saving technique first in Western Canada

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Federal funding

may be ending, but frailty still matters By Russell Williams and John Muscedere he federal government has announced the end of funding for its Networks of Centres of Excellence (NCE) program. This is not good news for Canadians. The program has long been touted as the jewel of the federal government’s sciences research support –and programs around the world have been modeled after it. What makes it special? The program funds pan-Canadian networks that focus on issues of wide benefit and interest to Canadians. These networks overcome the barriers of geography, academic disciplines, sectors and silos by linking like-minded science-based researchers, knowledge users, citizens, not-for-profit organizations, students and industry – for anywhere between five and fifteen years. The NCE funded networks pool efforts and resources to do what no single organization or group of researchers can do alone. In addition to funding research, NCE networks mobilize research evidence into policy and practice changes. They also provide training for the next generation of scientists, academics and clinicians that is not available within the confines of traditional academic or professional training. Now that’s all over. The government announced a New Frontiers in Research Fund that will be phased in to replace the

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federal NCE program and will support research that is “fast-breaking and high-risk.” While government funding for scientific research is welcome, this new fund does not offer the longer-term funding required to put that research to work to benefit Canadians and our economy. The unique training NCE networks provide will also be lost. And perhaps most notably, the value of distinct communities devoted to areas of importance to Canadians is lost. When an NCE network is established, it is with the understanding that there could be a stable 15 years of funding – so substantive issues can be tackled and plenty can get accomplished. In providing long-term funding, the NCE program recognized that there are no quick fixes when it comes to complex challenges around important issues for the health, safety and well-being of Canadians. The loss of the NCEs will be felt across the country. And not just in academic settings. As an example, the Canadian Frailty Network (CFN) was funded under the NCE program in 2012 and is Canada’s only network focused on improving care for older adults living with frailty and supporting their caregivers. An integral part of its work involves patients and citizens in all activities – from priority setting to evaluation. With the cancellation of the NCE program, CFN’s funding will stop in 2023 at the end of its second term. Continued on page 7

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Russell Williams is Chair of the Board of Directors of Canadian Frailty Network, and Senior Vice President, Mission, at Diabetes Canada. He is also is a member of the Board of Directors of BioCanRx, an NCE network. Dr. John Muscedere is the Scientific Director and CEO of Canadian Frailty Network. He is also Professor of Critical Care Medicine at Queen’s University, and an intensivist at Kingston Health Sciences Center. ASSOCIATE PARTNERS:

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Monthly Focus: Gerontology/Alternate Level of Care/Home Care/ Rehab/Wound Care: Geriatric medicine, aging-related health issues and senior friendly strategies. Best practices in care transitions that improve patient flow through the continuum of care. Rehabilitation techniques for a variety of injuries and diseases. Innovation in the treatment and prevention of wounds.

Monthly Focus: Healthcare Transformation/eHealth/Mobile Health/Medical Imaging: Programs and initiatives that are transforming care and contributing to an effective, accountable and sustainable system. Innovations in electronic/digital process in healthcare, including mHealth. A look at medical imaging techniques for diagnosis, treatment and prevention of diseases.

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NEWS

From collection to results, new laboratory technology makes testing faster and safer By Katherine Nazimek eing admitted to hospital goes hand-in-hand with a lot of testing, from pathology samples to check for cancer, to blood tests and transfusions. A single sample could change someone’s life: proof that they are illness-free, or a diagnosis that triggers the start of treatment. One mislabelled specimen or inaccurate test could have fatal consequences. Over the past few years, Sunnybrook Health Sciences Centre has expanded its use of innovative technologies to make sure those tests and transfusions are done more accurately, beginning with sample collection.

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BARCODING SYSTEMS HAVE BEEN INCREASINGLY USED IN HOSPITALS AROUND THE WORLD TO CUT THE RISK OF PATIENT MISIDENTIFICATION. In the past, patients were given wristbands with stamped patient information or identification. These wristbands were manually checked by hospital staff to make sure the right test or procedure was being done. But there was always room for human error. “One in 2,000 times they would have either the wrong name or the wrong blood in the tube, and you would have an error,” says Dr. Jeannie Callum, Director of Utilization for the Department of Laboratory Medicine & Molecular Diagnostics at Sunnybrook. “That’s just what the human error rate is for sample collection, and it’s very consistent hospital to hospital.” Barcoding systems have been increasingly used in hospitals around

the world to cut the risk of patient misidentification. And in 2016, Sunnybrook began to roll out a hospital-wide barcoding system, called electronic Positive Patient Identification (ePPID), to help prevent these errors for both lab samples and blood transfusions. With ePPID, patients are issued a barcoded wristband that, when scanned, provides the patient’s information and a unique patient identifier. This allows staff to confirm the patient’s identity and label samples at the bedside, track collection in real time and, where applicable, ensure that the correct blood product is transfused. “This approach reduces the risk of patient and specimen misidentification significantly; to one in every 15,000, from one in 2,000,” says Callum. Next comes blood testing. After blood samples are collected and barcoded, they are delivered to Sunnybrook’s new Core Laboratory on foot or through the pneumatic tube system – a two-way highway that lives between the walls of Sunnybrook and connects the lab to 25 patient care areas throughout the hospital. Within the 15,000 square-foot Core Laboratory is Ontario’s first endto-end automated biochemistry lab, where blood samples can go from receipt to result uninterrupted and without ever being touched by an operator. “Previously, laboratory staff would need to intervene at each step of the testing process, loading and unloading specimens onto specialized instruments that would prepare samples and conduct testing,” says Lisa Merkley, Director of Laboratory Medicine & Molecular Diagnostics at Sunnybrook. “Less human intervention means less opportunities for error,” adds Dr. David Hwang, Chief, Laboratory Medicine & Molecular Diagnostics. “It means increased efficiency, faster

In Ontario’s first in-hospital end-to-end automated biochemistry lab, blood samples can go from receipt to result uninterrupted and without ever being touched by an operator.

With the electronic Positive Patient Identification (ePPID) system, patients are issued a barcoded wristband that, when scanned, provides the patient’s information and a unique patient identifier. turnaround times, and the ability to reallocate resources to provide better quality of care.” In the new lab, a highly specialized team of technologists, technicians and biochemists work around the clock, utilizing the Roche state-of-the-art laboratory automation system for both testing and specimen archiving. To-

gether, the experts and the machine process approximately 4.5 million tests per year for Sunnybrook patients, community hospitals, government and research agencies, and private laboratories throughout central Ontario. Take a look behind the scenes of the automated biochemistry lab at H Sunnybrook.ca/mag. ■

Katherine Nazimek and Monica Matys are Communications Advisors at Sunnybrook Health Sciences Centre. www.hospitalnews.com

FEBRUARY 2019 HOSPITAL NEWS 5

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IN BRIEF

Expanding access to innovative palliative approach that will improve end-of-life care he Canadian Foundation for Healthcare Improvement (CFHI) recently announced that it is working with seven organizations across five provinces and one territory to spread Embedding Palliative Approaches to Care (EPAC). EPAC is a proven innovation that helps staff in long-term care identify residents who could benefit from a palliative approach to care, have conversations with them and their families about what they want, and develop and implement comprehensive care plans. Palliative care improves the quality of life for people with life threatening conditions and their families, helping to manage their pain and other physical, psychosocial and spiritual issues, make informed decisions about aggressive treatments, and helping them to die in their place of choice. CFHI will provide funding to support the following organizations to spread the approach to 22 homes in this initial expansion. • Yukon Health and Social Services • Institute for Continuing Care Education and Research (ICCER), Alberta • Parkwood Seniors Community, Waterloo, Ontario • Haliburton Highlands Health Services, Haliburton, Ontario • Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Mauricie-et-du-Centre-du-Québec, Quebec • New Brunswick Association of Nursing Homes • Western Health, Newfoundland and Labrador Using a train-the-trainer approach, this model will then be spread throughout regions where participating organizations have regional responsibilities. EPAC was developed by a team at Vancouver Coastal Health in British Columbia and implemented in 48 long-term care homes. From April

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2014-March 2018 the program resulted in a 56 per cent decrease in emergency department transfers, and a 45 per cent reduction in number of days residents spent in acute care in the last three months of their life. In 2017, CFHI identified it as an innovation ready for scale as part of its Call for Innovations in Palliative and Endof-Life care. The EPAC approach supports healthcare teams in long-term care to: • identify those residents who would benefit from a palliative approach to care, • discuss goals for care with the resident/substitute decision maker, and • develop and implement a comprehensive care plan that is unique to the needs and wishes of each resident. Offering a common, consistent approach to supporting residents who are near the end-of-life creates opportunities – and provides permission – for death and dying to be openly disH cussed, normalized and supported. ■

Opioid injecting linked to substantial rise in bacterial heart infections

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Federal funding CFN is devoted to an enormous concern today – how we care for older Canadians. In the 2016 Census, Canadians 65 years and older outnumbered children for first time. The most rapidly increasing segment of the population is individuals over 80 years old and over 50 per cent of those over the age of 80 are frail. For certain populations such as indigenous and veterans, frailty onset is earlier and significantly higher. A large, growing proportion of our health and social care spending is, and will increasingly be, focused on older Canadians living with frailty. From a societal perspective, frailty also places large burdens on family and friend caregivers, including financial, social and productivity costs. So what does the end of NCE funding mean for these Canadians?

13.4 admissions every three months (fourth quarter 2011) to 35.1 admissions every three months in the period afterwards. Whereas the percentage of opioid prescriptions attributed to controlled-release oxycodone declined rapidly when it was removed from the market by its manufacturer in the fourth quarter of 2011, hydromorphone prescriptions increased from 16 per cent at the start of the study to 53 per cent by the end. The researchers expected that an increase in risk of infective endocarditis would occur when controlled-release oxycodone was removed from the Canadian market; however, they found that the rise began before removal. “Although our observations do not support our hypothesis that the loss of controlled-release oxycodone increased the use of hydromorphone, they do support our suspicion that hydromorphone may be playing a role in the increasing risk of infective endocarditis,” says coauthor Dr. Michael Silverman, associate scientist at Lawson and associate professor at Schulich School of Medicine & Dentistry. The increase in the risk of infective endocarditis is consistent with the findings of other studies, but the observed H timing of the increase was novel. ■

study of people who inject drugs found a significant increase in the risk of infective endocarditis, a serious infection of the lining of the heart, possibly linked to increasing use of the opioid hydromorphone. The study is published in CMAJ (Canadian Medical Association Journal). Infective endocarditis can be life-threatening. “We observed a substantial increase in the risk of infective endocarditis among people who inject drugs, which is associated with hydromorphone’s increasing share of the prescription opioid market,” write the authors, including first author Dr. Matthew Weir, associate scientist at Lawson Health Research Institute and assistant professor at Schulich School of Medicine & Dentistry, Western University, London, Ontario. Researchers looked at Ontario data on drug users from linked health administrative databases at ICES between April 2006 and September 2015. There were 60,529 admissions to hospital of people who inject drugs and, of these, 733 had infective endocarditis linked to injecting drugs. Although admission rates for people who inject drugs were stable over the study period, the risk of infective endocarditis increased from

Continued from page 4

Significant transformative research currently underway will not be mobilized into practice and policy. There will no longer be a focused, coordinated approach to putting research evidence into practice to not just treat, but delay, frailty and improve older Canadians’ quality of life. Canadians committed to this task – researchers, patients and their caregivers, clinicians, policymakers and others – will no longer have a forum to exchange ideas and learn from completed research. Training the next generation will fall by the wayside, and frailty research will not align with the objective of “fast-breaking and high-risk” research under the new Research Fund. The need for system change is real and significant for older Canadians,

their families, and for those on the front lines delivering care. Who will take on the mantle to focus on older adults living with frailty? Frailty is just one example of the challenges addressed by the NCE approach. There are other NCE networks producing socio-economic benefits for Canadians by addressing equally complex problems such as those posed by cancer, the arctic, marine environments and technology in aging. These will also be lost when the NCE program ends. Alternative funding mechanisms are needed to sustain the outstanding work of the Canadian Frailty Network and other NCEs so that Canadians can continue to reap the return on the government’s H investment. ■

FEBRUARY 2019 HOSPITAL NEWS 7

NEWS The new HSC Winnipeg Women’s Hospital.

Are all systems go? Inspecting every single element of a nearly 400,000 square-foot new hospital re all systems go? That’s the question that needs to be answered during the commissioning of the new HSC Winnipeg Women’s Hospital. “Throughout the construction process, we examine the quality of construction and installation, and test each building system,” explains Bill Algeo, Building Technologist and HSC’s Commissioning Authority for the Women’s Hospital Redevelopment Project (WHRP). “The integrated commissioning process enables us to confirm that equipment and systems are functioning as intended, and identify any challenges for the contractor to resolve prior to the building handover.” Bill leads a team of skilled tradespeople and supervisors examining their own particular area’s specialized systems. At any given time there are 15 to 20 people inspecting, documenting and testing different areas and systems in the building. Consultants only spot check the work quality and progress, so the

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HSC commissioning team inspects every single element of the nearly 400,000 square-foot building and checks them against the design. For example: are the installed toilets the water-saving type specified, and are they functioning correctly? Is the drywall painted flawlessly? Are the windows sealed correctly? When deficiencies are found, the commissioning team documents them for various consultants to the contractor for resolution. Deficiencies can run the gamut from a nick in the wall, to incorrect installation or operation of a piece of equipment or improper function of an entire system. For example, the team may find that an installed product is different from the original specification. Simple substitutions are often inevitable given the time between design and build, as products may have new versions or may have been discontinued. The typical process for a substitution is for the builder to advise the consultant in advance. The change would

be evaluated to determine whether it is an equal product. This process can impact timelines and potentially increase costs. Actual errors can be both time-consuming and costly, especially if rework is necessary. The HSC team continues follow-up inspections to confirm that all deficiencies are corrected. Physical examination of the construction is only one part of the commissioning process. Every electrical and mechanical system must also be inspected and tested to make sure water flows, elevators run, lights go on, and heating and cooling systems operate as appropriate. Each system is tested independently, from end to end. Then they are tested to see if they perform correctly as they integrate with the other building systems. “We’ll make sure that when a fire alarm is pulled the alarms ring, lights flash, the right doors unlock, and the elevators shut down,” says Bill. “This process is incredibly detailed and important because every building

design is different, and the interrelated systems must work in concert, as designed.” “Every test is also a learning experience,” he continues. “We have learned from every previous project we’ve commissioned and have developed very specific equipment tests.” As each system is examined and tweaked to ensure proper functioning, the team moves on to testing interdependent systems. “It’s not enough to know that each system works on its own,” says Craig Doerksen, Divisional Director, Facility Management, and a member of the WHRP Steering Committee Executive. “We have to make sure they work together too.” To illustrate, he uses the example of showers. “Each shower must be tested individually. Is the tap installed correctly? Does the water come on when you turn on the tap?” Craig says. “Do both hot and cold water flow as they should? Does hot water reach the right temperature? How long will hot water last?” www.hospitalnews.com

NEWS One of the patient washrooms at the new HSC Winnipeg Women’s Hospital. “Now, does the exhaust fan work properly? Is the mirror fogging up? Are the tiles getting slippery or is the floor surface still skid-proof?” The relationships grow in magnitude and scale. “So we know what happens one room at a time. But what if everyone on the floor turns on the shower at the same time? What if 10 of those people shower for 30-minutes each? Is there enough hot water? Is the steam to hot water converter big enough? Is there enough water pressure from the pumps?” That’s just the showers. Every electrical outlet in the building must be tested. Every light switch. Every data jack. And on it goes. Painstaking attention is paid to every detail because at the end of the day, HSC Facility Management is responsible for ensuring the care and safety of everyone and everything inside the building. The process continues until the contractor and HSC’s commissioning

team are confident that all systems are working properly. Then they are ready to do a dry-run to test the Life Safety Systems. “We throw the switches for complete loss of power,” says Craig. “We need to know with absolute certainty that the building and ultimately the people inside it will be safe under extraordinary circumstances. We look at the redundancies that are built in to ensure backup systems come on and function as they are supposed to.”

From there, the team pulls together all the players for the consultants’ Life Safety Test rehearsal. Each consultant responsible for the project, be they mechanical, electrical, structural, and/or architectural, must witness the functionality and provide letters of certification to confirm their respective designs are reflected in the actual building and work for their intended purpose. Rehearsals continue until the team is satisfied that it will successfully pass the Life Safety Systems test with City

of Winnipeg inspectors. Consultants prepare their verification letters to accompany the application for an interim occupancy permit, and the City of Winnipeg inspectors set the time and date for the test. Once the building successfully passes the test and the building design team warrants that the project is substantially complete, the City grants the occupancy permit. At this point, HSC takes on full responsibility for the building and moves into the next phase of readiness preparation for opening. HSC will need several months following substantial completion to install, test and prepare staff, equipment, work processes, and clinical systems. Simulations of the move itself will also be run as opening day nears. Once HSC is confident that care can be provided safely, the new HSC Winnipeg Women’s Hospital, at all systems go, H will welcome its first patients. ■

This article was submitted by HSC Winnipeg.

ACUSON Sequoia™

Taking Ultrasound to New Heights The return of an icon. In image quality, color sensitivity, and advanced imaging modes, ACUSON Sequoia was – and still is – an industry benchmark. The new ACUSON Sequoia is a remarkable evolution of a product that was so right in so many ways. • Address patient’s unique bioacoustic characteristics • Personalize when it matters • Easy to learn, easy to love siemens-healthineers.ca/sequoia

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FEBRUARY 2019 HOSPITAL NEWS 9

NEWS

New life-saving technique first in Western Canada By Carrie Stefanson ancouver General Hospital (VGH) is the first hospital in Western Canada to use a new device to help save the lives of patients at risk of dying from a traumatic injury, such as a fractured pelvis or gunshot wound. Resuscitative endovascular balloon occlusion of the aorta or REBOA is a technique where trauma and emergency teams place a balloon in the patient’s main artery from the heart to stop fatal bleeding. “REBOA extends what we’re able to do for our patients in that golden hour when they arrive at our hospital and are hemorrhaging,” says Dr. Naisan Garraway, Medical Director, Trauma Services, Vancouver Coastal Health. A temporary balloon is placed in the patient’s aorta, via the large artery in the thigh (femoral artery). Once inflated, the balloon blocks blood flow to the wound, while still allowing blood to reach the brain and heart. This prevents patients from “bleeding out,” or dying of internal bleeding. With the balloon in, the clock is ticking. Emergency and trauma staff have about 45 minutes to provide life-saving measures to stabilize the patient for surgery. REBOA was first used on a patient in critical condition with multiple gunshot wounds to the abdomen. Less than 30 minutes after arriving at VGH, surgical and trauma teams led by Doctor Emilie Joos, performed REBOA. “For me, the decision was simple: either I would inflate this balloon in the patient’s aorta or he would die on the operating table,” says Dr. Joos. “The REBOA allowed me to find and control bleeding from multiple injuries, without worrying about blood loss.” Major trauma is one of the leading causes of death for people under age 45 in Canada. More than 700,000 people are injured yearly in BC. Of these,

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(above) Staff at VGH perform REBOA. (right) The balloon used in REBOA. approximately 1,800 die, 9,000 suffer permanent disability, and 27,000 are hospitalized. VGH is one of two Level 1 adult trauma centres in BC, providing the most advanced trauma services. “Implementing REBOA at VGH helps us to continue to be on the leading edge of trauma care,” says Dr. Garraway. “This new tool and the expertise of our emergency and trauma staff can only benefit the most critically injured patients in our province.” REBOA has its origins in the battlefield. It’s an advanced version of a catheter first used by military trauma surgeons to stop bleeding from gunshot wounds. It was introduced in the U.S. in 2016, followed by Europe and Canada.

Vancouver Coastal Health is responsible for the delivery of $3.3 billion in community, hospital and residential care to more than one million people in communities including Richmond, Vancouver, the North Shore, Sun-

shine Coast, Sea to Sky corridor, Powell River, Bella Bella and Bella Coola. VCH also provides highly specialized care and services for people throughout BC, and is the province’s hub of H health care education and research. ■

Carrie Stefanson is the Public Affairs Leader, Vancouver Coastal Health. 10 HOSPITAL NEWS FEBRUARY 2019

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NEWS

Building community ownership:

A new way for hospitals to engage the public By Sarah Hartwick uilding a new, modern health and research centre in the heart of Ottawa is about health care – and it’s about the community. The Ottawa Hospital is in the early stages of planning a brand new healthcare centre in the heart of the nation’s capital to replace its aging Civic Campus. Like the Civic before it, the new campus will be Eastern Ontario’s regional trauma centre, and will provide acute, specialized and complex care to the region’s 1.3 million residents. Public involvement is essential in planning the new facility – it means stronger health outcomes, collaboration on publicly-accessible spaces, and integration into the community. A key part of involving the public is the creation of the new Campus Engagement Group, which began meeting in 2018. This group will take a deep dive into issues like access and transportation, greenspace, parking and design, that have been consistently rated as most important by the public. These issues are rooted in individual values and are too complex to solve using traditional consultation methods like town halls. “The hospital has hit upon a great idea for getting the community more deeply involved in this project. As members of the Campus Engagement Group, we will have an opportunity to debate key issues facing the hospital and the community and to make our voices heard at the most senior levels

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of the organization. Together, we can find solutions that really work.” says group co-chair Paul Johanis, who is the current Chair of the Ottawa-based Greenspace Alliance. The group’s 18 members includes community leaders from local neighbourhood associations and groups who advocate for seniors, greenspace, heritage, the Central Experimental Farm, patients, and people who have disabilities. The group was created based on recommendations in the third-party engagement report Setting the Stage, Turning the Page. It will make recommendations to the hospital’s Board of Governors by deliberating, comparing perspectives and identifying possible compromises together. The Campus Engagement Group is one of three ways the hospital is engaging the public on the new campus, alongside online activities and in-person events such as community town halls. “Hospitals in the 21st century need to be integrated into their communities, and The Ottawa Hospital is fortunate to be part of a passionate community with leaders who want to be involved.” says Bernie Etzinger, the hospital’s Chief Engagement Steward. “Their work on the Campus Engagement Group will be critical in making sure we build the best possible healthcare facility.” To learn more about The Ottawa Hospital’s new campus, visit www. H GreaterTogether.ca. ■

Sarah Hartwick is a Communications Coordinator at The Ottawa Hospital. www.hospitalnews.com

Paul Johanis is co-chair of the Campus Engagement Group and present Chair of the Ottawa-based Greenspace Alliance.

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FEBRUARY 2019 HOSPITAL NEWS 11

NEWS Mackenzie Vaughan Hospital

Healthcare infrastructure projects in Ontario By Michaela MacPherson ealth care infrastructure projects across Ontario are bringing with them more automated facilities, diagnostic equipment, cancer treatment centres, hospices, operating rooms and other enhancements. Even more important than bricks and mortar, these facilities are helping to improve care and provide a better environment for recovery. Infrastructure Ontario is proud to help deliver critical health care infrastructure to Ontarians with an internationally recognized performance record for building large, complex projects. Here is a look back on projects that reached major milestones in 2018.

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COMPLETED PROJECTS ErinoakKids Centre for Treatment and Development Earlier this year, ErinoakKids opened three new facilities – one in Brampton, a second in Oakville and

a third in Mississauga. These replace a patchwork of 10 mostly leased and undersized facilities to three modern regional centres, in order to offer better co-ordinated care and supports for children and youth, and giving clients and families access to all of their services under one roof. The new, fully accessible buildings provide more and better spaces for services such as occupational, physical and speech therapy, infant hearing screenings, vision services and autism services. Fully accessible outdoor playgrounds, indoor playrooms, gyms, and climbing walls are just a few of the amenities enabling clients to engage in playbased therapy. Features like “truth windows” that reveal elevator shafts moving between floors, tactile furniture, welcoming colours and artwork are integral to the kid-friendly design of the buildings. The Brampton site includes a 26-bed respite centre; the largest in Ontario equipped to care

12 HOSPITAL NEWS FEBRUARY 2019

for children who are medically fragile, technology dependent, require complex care or are diagnosed with autism. Milton District Hospital In fall 2018, the Milton District Hospital expansion project attained the Leadership in Energy and Environmental Design (LEED) gold certification for new construction with the Canada Green Building Council, surpassing its goal of LEED silver. The project added 330,000 square feet to the existing 125,000 square foot hospital, and was completed in spring 2017 to meet the increasing care needs of Canada’s fastest growing community. Through this expansion, Milton received a 50 per cent increase in inpatient bed capacity, a new MRI machine and other expanded services, such as emergency, surgical, critical care, maternal newborn and diagnostic imaging.

Credit Valley Hospital Credit Valley Hospital celebrated the completion of the third phase of its 20 year expansion plan that has added more space to priority areas for more patients. The hospital marked the momentous occasion with an official ribbon cutting on November 22. The project has improved patient experience, medical technology and created more space to care for the community which includes 187,000 square feet of renovated space and 20,000 square feet of new space for patient care, as well as 12 new or renovated operating rooms.

PROJECTS IN CONSTRUCTION Brockville General Hospital After nearly two decades of planning, ground broke on the largest public infrastructure project in Brockville’s history in the spring. The project will bring a new addition and www.hospitalnews.com

NEWS

West Park Health Centre

renovated spaces to the hospital’s Charles Street site. Once completed, all hospital programs and services will be under one roof. The addition will increase the hospital’s total bed capacity, including an increase in single-patient rooms. The project will improve access to palliative, restorative, continuing and mental health-care. Michael Garron Hospital This spring, construction kicked off on Michael Garron Hospital in East York. The project involves the construction of an eight-story patient care tower and demolition and renovation of select areas of the existing facility. The redevelopment will enable the delivery of high-quality patient care, while replacing some of the oldest spaces within the hospital. West Park Healthcare Centre West Park helps individuals manage health challenges like lung disease, diabetes, stroke, amputation and musculoskeletal issues. Early construction work is underway for a new six-story, approximately 730,000 square foot facility on the healthcare centre’s campus in Toronto. It will accommodate rehabilitation and complex continuing care beds, expanded outpatient services and community living and outreach programs. Extensive landscaping of the greenspace around the site will allow West Park to keep the “park” on its 27-acre campus. Patients, staff and visitors will have captivating scenic views of nature and access to safe, accessible walking pathways, so that indoor therapy areas can be easily extended to the outdoors. ErinoakKids Centre for Treatment and Development

Mackenzie Vaughan Hospital This fall, exactly two years after breaking ground, the $1.3 billion Mackenzie Vaughan hospital reached its highest point in construction. This is the first hospital to be built in the city of Vaughan, and the first new hospital to be built in York Region in the last 30 years. Once completed, the new hospital will include a state-of-the-art emergency department, modern surgical services and operating rooms, advanced diagnostic imaging, specialized ambulatory clinics and intensive care beds. Approximately 90 per cent of acute-care patient rooms will be single-occupancy for infection prevention and control. It will be the first hospital in Canada to feature fully integrated

“smart” technology, which features systems and medical devices that can speak directly to one another to maximize information exchange. Groves Memorial Community Hospital The new Groves Memorial Community Hospital being built in Aboyne, Ontario, between Elora and Fergus, celebrated a major construction milestone with a topping off ceremony this fall. The new hospital will replace the existing Groves Memorial Community

Hospital in Fergus. The project includes more space for emergency, ambulatory, diagnostic and inpatient services to accommodate a growing community; modernized infection control measures, including additional isolation facilities, to enhance the hospital’s ability to respond to a pandemic or disease outbreak; an onsite helipad to allow for faster access to patient transfers by air ambulance and large windowed areas that allow natural light to penetrate deep into the building and ultimately H connect the interior with the outside. ■

Michaela MacPherson is the Communications Advisor at Infrastructure Ontario.

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FEBRUARY 2019 HOSPITAL NEWS 13

DOCTORS WITHOUT BORDERS

Memorial By Courtney Bercan

ears later, I still don’t want to think about it, let alone type it out. Three children, babies practically, dead before me. Their parents, dead beside them. It is now two years since I was on Doctors Without Borders search and rescue vessel in the Mediterranean and it’s been a slow path, at times, to finding healing and peace for the things we saw and experienced there. As my life settled into a predictable rhythm, the memories started coming out of the blue and with intensity. They demanded attention. Normally in Canada, the process of finding closure for a patient’s death, while not always easy, is not usually this difficult. There are mitigating thoughts and phrases to help you along the way: “They were elderly and had had a good life.” “We did everything we could.” “At least now they are out of pain.” As health care professionals we rely on these phrases to keep us sane. But what do you tell yourself when none of them apply? Theirs’ were the littlest bodies we recovered that day; their lives were short. Their time in Libya would have been characterized by deprivation and fear. Their parents would have agonized over whether to board an over-crowded dinghy with no life jackets, no realistic chance of making it to Europe, and little guarantee of rescue if they don’t. The trip would have been terrifying, uncomfortable, and exhausting. The sun beating down on them. Their throats parched after having run out of water. Fuel sloshing around the boat – stinging and burn-

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Courtney Bercan on the Doctors Without Borders’ search and rescue vessel. ing their skin. I find it difficult to think about the flash of hope they must have had when they saw our rescue boat on the horizon. But then, someone slipped into the water, destabilizing the boat and the collective psyche. Panic ensued. The flimsy dinghy started to collapse and the women and children in the middle and those sitting along the edges would have been amongst the first victims. It’s impossible to piece together the exact sequence of events for many of those who drowned further than that. But what struck me about these babies when they were brought, lifeless, onto our ship was that they were

plump. They were healthy and filled with potential until they drowned moments before we reached them. They didn’t even have a chance. There are no pat phrases in this scenario. No comforting words. I have one specific memory that I have been suppressing that I rarely let my mind form a full picture of. When I do, I am watching it from above – like it wasn’t really me there experiencing it. I try not to get too close to it. I definitely can’t think about the cold skin, the tiny fingers, the wet clothes, the smell of gasoline…the fuel blisters. I really can’t handle the blisters. I comfort myself with the thought that anyone who has worked with Doctors

Without Borders has got to have these “out of the question”, “no-go zones” in their mind, right? This is normal… right? But the truth is, I knew it was time to “go” there because months later, whether on a busy bus or an idyllic hike, this memory, amongst others, returned. It felt identical to that moment on the boat: The rock of sadness manifesting as a chest so tight it’s difficult to breath. A rapid pulse. A lump in my throat so big that I had to bite my cheeks to keep down. My squeaky voice replying, “I’m fine” to a colleague who knew, I clearly wasn’t. I knew they weren’t either. How could they have been? Continued on page 45

Courtney Bercan worked with Doctors Without Borders on a migrant search and rescue vessel in the Mediterranean in 2016, the Dignity 1. In December 2018, the organization was forced to stop operations of its last rescue boat in the Mediterranean, the Aquarius, due to political pressure from several European countries. This news triggered harrowing memories for the Vancouver nurse. 14 HOSPITAL NEWS FEBRUARY 2019

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NURSING PULSE

Paid to play By Jonathan Sher

t may seem quite the hike from Rwanda to Western University in London, Ontario, but for nursing student Amy Olson, the trip takes minutes thanks to the technological wizardry of a professor, RN Richard Booth. Using a robot that Booth obtained, Olson controls its movements remotely in Africa, navigating hallways to a classroom, then engaging with her Canadian peers and teachers through a tablet mounted nearly head-high. This use of technology is but one innovation from the bubbling imagination of Booth, who can hardly believe he’s paid to play. “I’ve got the sweetest job in the world,” Booth says. “I get to play with robots. I have three robots sitting in my office right now. I get to see how they work in health care, how we can create nursing roles to work with them, and (how we can grow) nursing roles.” Booth was a teenager in Guelph in the late-1990s when he caught the techno-bug, creating websites and engaging in multiplayer video games with people across the world. While his parents questioned if he was wasting time, Booth was enthralled and certain the then-clunky connection to an expanding ‘Internet’ was the future. “It was life-changing when I realized I could talk to people on the other side of the planet,” he says. “I couldn’t understand when I got to undergrad (nursing) why other people didn’t see its potential.” Booth’s grandmother and aunt had been nurses, and his older sister was training to become one. He pursued nursing too, but not simply because it was in his blood line. He also wanted to make good on the sacrifice of his parents by choosing a well-marked path to becoming a professional. He was an undergrad at McMaster University in Hamilton when Ruta Valaitis, who

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would serve as a mentor, set him on a course he’s taken ever since. “She’s the person who, in 2002, said ‘Richard, your career will be (in e-health).’ She saw something in me that I didn’t know. I always liked technology. I always liked innovation. But

at that point in nursing, there really wasn’t a creative outlet for that.” Earning a master’s degree in digital education at Western University in 2007, opportunity arrived the day after graduation and took the form of a job offer from RNAO to create a course

RN Richard Booth uses robots to enhance nursing roles and explore innovation. Photo credit: Western University

on e-health and nursing. RNAO’s support “was huge. (The) world had really moved forward by a quantum leap, and RNAO recognized that,” he says. Later, Booth earned his PhD at Western, studying the way nurses interact with technology. While some may resist the digital pull, the growth of technology has made resistance futile. “I guarantee that person who had grumblings 10 years ago has an iPhone in their pocket right now.” Technology is also changing the way nursing students are taught. As part of course work this academic year, Booth will have students play a medication administration video game. As any gamer knows, the way to improve is through repetition, and the medication game will help students work out the kinks before they deal with real patients or train in costly simulator labs. He expects to roll out a second video game next year. In that one, students will role play as nurses in the home of a patient with advancing dementia. “If you make a poor decision in this game, no one is going to get hurt, and then you can learn from it.” Booth is also dreaming up ways to use virtual reality so students can practise skills while getting sensory feedback. He wants to create something that will allow students to do virtual intramuscular injections and feel the force on their fingers. But while his visions are futuristic, his pursuit is practical. For-profit companies are carving out niches in health care with apps that enable genetic testing and virtual consults with doctors, he says. If nurses don’t take the lead, companies seeking profit may shape the future of the profession. “We’ll essentially be using technology that is created by someone else who doesn’t have nursing or maybe the client’s best interest in (mind). So we need to be advocating, we need to be H leading this stuff.” ■

Jonathan Sher is senior writer for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. This article was originally published in the November/December 2018 issue of Registered Nurse Journal, the bi-monthly publication of the Registered Nurses’ Association of Ontario (RNAO). 16 HOSPITAL NEWS FEBRUARY 2019

www.hospitalnews.com

Providence Healthcare

leverages technology to improve outbreak notifications By Emily Dawson istorically, when an outbreak was declared at Providence Healthcare’s long-term care home, staff and volunteers would have to scramble to manually call the families or Substitute Decision Makers for all 288 residents who live in the close-knit, active community. “When evaluating the efficacy of manual calls, we noted a few barriers to providing consistent, accurate and timely notifications,” says Aurora Wilson, Providence’s manager of Infection Prevention and Control (IPAC). “The process was time-consuming and took clinicians away from care during critical moments in an out-

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break situation. We also found the communications were inconsistent, as we would have clinical and non-clinical staff – and sometimes volunteers – making these calls. The call process definitely added to stress and frustration of staff amidst an outbreak.” Now, an automated mass-calling system has been implemented for whenever there’s an outbreak at the Cardinal Ambrozic Houses of Providence long-term care home. During an outbreak, Providence notifies families and Substitute Decision Makers for several reasons: to keep other residents and visitors safe by minimizing the spread of infection through awareness; to maintain orga-

Join us for the 2019 conjoint conference of the International Federation of Infection Control and Infection Prevention and Control Canada.

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For registration and information: www.ipac-canada.org Tel: 1-866-999-7111 or 204-897-5990 Email: info@ipac-canada.org

Automated mass calling project team members gather in the Houses of Providence. Clockwise from top left: Pat Colucci, Aurora Wilson, Shiva Nadarajan, Jube Walker, and Maggie Bruneau. nizational transparency; and to help everyone make informed decisions about visiting. When an outbreak is declared, the system allows the IPAC staff to select the affected unit, and it then uploads the contacts to the automated dialer’s portal and initiates the communications. If a call is answered or goes to voicemail, families hear a standardized script with the outbreak details. The system is programmed to repeat the call when there is no answer. “The automated calling system leaves the staff to care for the residents and implement outbreak measures. For families, the system offers a standardized message that’s clear and concise. The message also directs them to a hotline if they have additional questions,” says Wilson. “There is room to grow and spread this system to Providence Hospital, and to have outbreak messages translated into different languages. Those would certainly be our end goals.” Wilson and her team presented the project at the GTA IPAC Education Day in late 2018 and it generated buzz among other long-term care providers.

“I admit I had some nerves on the first live auto call. But what I share with people is that there have been no glitches. It’s surprisingly simple, it works, and it’s leveraging technology, which is the way the healthcare system’s heading,” she says. A robust report is immediately available after the automated call. It tracks the number of people reached, whether it was a live pick-up or voicemail, out-of-service numbers, no answer or busy lines. After a recent respiratory outbreak affecting two units in the home, the system generated 64 calls, of which 78 per cent were answered (live or voicemail), 15 per cent went unanswered or reached a busy line, and seven per cent had invalid numbers. The call is followed by an e-mail blast to families as an added layer of communication to ensure that everyone is reached. “One unintended, positive outcome is the opportunity to improve our record-keeping. The system tracks invalid phone numbers, so we’re able to clean-up our database, or seek updated contact information, as we go,” H Wilson adds. ■

Emily Dawson is…at Unity Health Toronto? 18 HOSPITAL NEWS FEBRUARY 2019

www.hospitalnews.com

INFECTION CONTROL 2019

International Infection Control Conference rom May 26-29, 2019, a historic education conference will be held in Québec City. This will be the first conjoint conference of the International Federation of Infection Control (IFIC) and Infection Prevention and Control Canada (IPAC Canada). Held at the impressive Québec Convention Centre, the conference is expected to attract 700 infection prevention and control professionals worldwide. An international Scientific Program Committee has developed an inspiring and creative education program. Attendees will have their choice of sessions including current issues in antibiotic resistance and immunization; cleaning and disinfection; hand hygiene; and the One Health Initiative. They will also have the opportunity to network with other attendees from around the world, developing relationships and learning how others approach and manage similar challenges.

real patient will set the tone for the conference.

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WHO ARE INFECTION PREVENTION AND CONTROL PROFESSIONALS?

Of primary importance to the theme of the conference is the Voice of the Patient. Attendees will be urged to ‘think outside the box’ when advocating for patient care, such as issues in unusual care settings, data collection, and patient engagement in their own care. The experienced story of a

Molly Blake RN BN MHS CIC is President of the Infection Prevention and Control Canada. She is an Infection Prevention and Control Professional in Winnipeg MB.

www.hospitalnews.com

An Infection Prevention and Control Professional (ICP) is an individual who is employed with the primary responsibility for policies, procedures, and practices that impact the prevention of infections. Integral competencies to the role include knowledge of infectious disease processes, microbiology, routine practices and additional precautions, surveillance, principles of epidemiology, research utilization and education. An ICP should be Certified in Infection Control (CIC®). We invite healthcare professionals from all settings to join us in Québec City for the 2019 IFIC/IPAC Canada Education Conference. For more information, visit www.theific.org or H www.ipac-canada.org. ■

Infection Prevention and Control Canada (IPAC Canada)/ Prévention et contrôle des infections Canada (PCI Canada) IPAC Canada is a national, multidisciplinary, voluntary professional association uniting those with an interest in infection prevention and control in 20 chapters across the country. It is committed to the wellness and safety of Canadians by promoting best practice in infection prevention and control through education, standards, advocacy and consumer awareness.

International Federation of Infection Control With members from nearly 50 countries, IFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare-associated infections worldwide. By being part of a network, IFIC members share experiences and publications and collaborate in improving infection prevention and control globally.

Terrie Lee RN MS MPH CIC FAPIC is President of the International Federation of Infection Control. She is an Infection Preventionist in Charleston, WV.

FEBRUARY 2019 HOSPITAL NEWS 19

INFECTION CONTROL 2019

SickKids-led research team uncovers a drug that disarms life-threatening bacteria By Vanessa Blanchar lostridium difficile (C. diff) is an antibiotic-resistant ‘superbug’ that causes life-threatening diarrhea and colitis (inflammation of the colon). It typically affects people who have recently received both medical care and antibiotics. C. diff causes disease by secreting a fleet of toxins that enter and destroy the cells of the colon. A team led by Dr. Roman Melnyk, Senior Scientist in the Molecular Medicine program at The Hospital for Sick Children (SickKids), that includes Hanping Feng, PhD, professor in the Department of Microbial Pathogenesis at the University of Maryland School of Dentistry (UMSOD), and Jacques Ravel, PhD, associate director, Institute for Genome Sciences (IGS) at the University of Maryland School of

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Medicine found a drug that can block the effects of the three deadly C. diff toxins without affecting healthy gut bacteria. This means a more focused and successful treatment of C. diff compared to current antibiotic treatments that can’t target these toxins. The U.S. Centers for Disease Control and Prevention listed C. diff at the top of the list of the 18 antibiotic-resistant threats in the U.S. There is an urgent need for therapies that prevent the symptoms of this disease without disrupting the healthy gut bacteria. C. diff continues to become increasingly more widespread and difficult to treat with traditional means. The team screened thousands of small-molecule drugs to determine if any of them could block the effects of the three deadly C.diff toxins

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without affecting the gut bacteria. They discovered that a drug called Niclosamide, approved in 1982 for use against human tapeworm infections, protected human colon cells from all three C. diff toxins by preventing their uptake into cells. The team’s findings were published in Nature Communications on Dec. 7.

This discovery could have profound impact on patient care. If these findings translate to humans, this would be the first drug to treat C. diff that is able to block all toxins to prevent disease and disease recurrence without affecting the gut bacteria. By repurposing an existing drug, new treatment can come to market sooner

THE U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION LISTED C. DIFF AT THE TOP OF THE LIST OF THE 18 ANTIBIOTIC-RESISTANT THREATS IN THE U.S. “C. difficile, commonly thought of as a disease of the elderly, is increasingly being seen in children,� says Melnyk, who is also an Associate Professor in the Department of Biochemistry at the University of Toronto. “When we embarked on this work, we knew that we needed to find a drug that was safe for humans. Recognizing that it can take over a decade to get a new drug to the clinic, we focused our efforts on old drugs that were already approved for human use.�

and it can be taken orally because it is an oral pill. The team will continue to conduct trials to further investigate whether Niclosamide represents a model for non-antibiotic drugs against toxin-producing infectious diseases. This work was supported by a grant from the Canadian Institutes of Health Research. It is an example of how SickKids is making Ontario Healthier, Wealthier and Smarter H (www.healthierwealthiersmarter.com). â–

Vanessa Blanchar is a Senior Communications Specialist at The Hospital for Sick Children (SickKids). www.hospitalnews.com

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INFECTION CONTROL 2019

Infection prevention is in your hands By Anne MacLaurin ealthcare-associated infections (HAIs), or infections acquired in healthcare settings, are the most frequent adverse event in healthcare delivery worldwide. Every year, 220,000 Canadian patients – approximately one in nine – will develop an infection during their hospital stay, and an estimated 8,000 of those patients will lose their lives (Zoutman et al., 2003). Complicating the problem is that many HAIs are caused by antimicrobial-resistant organisms (AROs). Without harmonized and immediate action, the world is facing a post-antibiotic era in which common infections could once again be deadly (WHO, 2015). AROs could lead to infections that are difficult, if not impossible, to treat. Action needs to happen on multiple levels to prevent the emergence of antimicrobial resistance, and special care must be taken to protect the most vulnerable populations. Patients are placed at risk of acquiring an infection each time they enter the healthcare system with an open wound or a suppressed immune system, when they require surgery or have an invasive device inserted, and from a myriad of other ways that are seemingly innocuous to the unaware. To better understand the magnitude of the problem, take the case of one senior who ping-ponged throughout the healthcare system and later died from a HAI: Herbert Strasser, a very active 72-year-old, collapsed at his home in Belleville, Ontario on the morning of August 3rd. One minute he was standing at the door drinking coffee, and the next minute he was literally a paraplegic lying on the floor. He was rushed to the local hospital and then on to Kingston General Hospital (KGH). Strasser was diagnosed with a disc decompression, requiring urgent sur-

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WITHOUT HARMONIZED AND IMMEDIATE ACTION, THE WORLD IS FACING A POSTANTIBIOTIC ERA IN WHICH COMMON INFECTIONS COULD ONCE AGAIN BE DEADLY. gery. He spent 10 days recovering before being transferred to a rehabilitation centre. He was there five days before being sent back to KGH for symptoms of a urinary tract infection. He stayed overnight in the ER, and was then transferred back to the rehab centre. Once back at the rehab centre, Strasser continued to deteriorate and after several days was sent back to KGH where it was determined he was septic from an abscess that had developed at the surgical site on his back.

22 HOSPITAL NEWS FEBRUARY 2019

He received antibiotics, an incision and drainage and was reassured that a very close eye would be kept on this infection. Over the next several days he lost his appetite, developed a severe thrush in his mouth and suffered episodes of chills and shakiness. Strasser desperately wanted to be transferred back home to be closer to his family. The doctors agreed he was stable and “there was nothing being done at Kingston that couldn’t be done at Belleville.” He was transferred

late one evening without pertinent transfer records; they were to follow. A physician-to-physician report did not occur and within 24 hours Strasser became quite ill with various issues. Prior to transfer a very important antibiotic for the spinal abscess was accidently discontinued. Within six hours of being transferred as a “stable” patient, Strasser tested positive for C. difficile. He was severely dehydrated, the thrush in his mouth persisted to the point where eating and drinking had become painful. Strasser was transferred to the ICU, where tragically he died on September 19th. Post mortem it was determined that the spinal abscess had not resolved, it had in fact crept up from the base of his spine to his neck and the infection was literally disintegrating his neck. The C. difficile was so severe his colon was macerated and the thrush in his mouth had extended all the way down his throat. Several healthcare improvements have since been made. At KGH, protocols were initiated to identify patients at high risk for C. difficile; transfers are limited on weekends and off hours; and physicians give doctor-to-doctor reports. The Belleville hospital made positive changes to medication reconciliation as well as communication between physicians. The rehab facility also made changes to address communication and nursing staff issues.

REDUCING hais Currently, there is not a consistent approach across provinces/territories or even within some provinces for how infections are defined, measured, or reported. The Canadian Patient Safety Institute is supporting a number of pan-Canadian initiatives to implement standardized surveillance definitions and leading a public awareness campaign – STOP! Clean Your Hands www.hospitalnews.com

INFECTION CONTROL 2019 Day – aimed at helping to change behaviours around cleaning your hands to help prevent infection. Under the leadership of Infection Prevention and Control Canada (IPAC Canada), in collaboration with the Association of Medical Microbiology and Infectious Diseases Canada (AMMI Canada) and the Canadian Patient Safety Institute, standardized surveillance definitions for HAIs in acute care and long term care have been identified. The nationwide adoption and application of these definitions will impact how infections are defined, measured and reported and ultimately reduce infections. Senior leaders are called upon to endorse, promote and use these case definitions within their jurisdiction, facility and/or network. In addition, the Public Health Agency of Canada, the Canadian Nosocomial Infection Surveillance Program, the Canadian Institute for Health Information, AMMI Cana-

da, IPAC Canada and the Canadian Patient Safety Institute are working in collaboration to identify potential strategies for national surveillance of HAIs. Good surveillance data and information is essential for improvement. The group seeks support to facilitate the collection, analysis and reporting of HAI surveillance data across Canada. Ultimately, this data will serve to reduce infections, like the HAI that ended Strasser’s life. As front line healthcare workers, there is something you can do right now to help prevent the spread of HAIs. Proper hand washing serves as the foundation to prevent HAIs: in Canada, the Canadian Patient Safety Institute promotes STOP! Clean Your Hands Day each year to foster engagement and participation. Improving the implementation of evidence-based practice in order to make patient care delivery safer depends on behaviour change (Michie et al, 2011), and events like these help provide the

tools and resources to encourage that behaviour change. STOP! Clean Your Hands Day highlights the dangers in not cleaning your hands, not only in healthcare, but also in our communities. If we are going to defeat HAIs, we should report them, honour the memory of those they affect, and face the problem with clean hands.

STOP! CLEAN YOUR HANDS DAY Cleaning your hands is one of the best ways to stop the spread of infection. In a Canadian Hand Hygiene audit the national compliance rate for hand hygiene was 78.3 per cent (CPSI, 2014). Current data estimates that compliance rates by province range from 48 to 90 per cent. Each year, thousands of healthcare providers in sites across Canada join the fight against the spread of infection by participating in STOP! Clean Your Hands Day – led by the Canadian Patient Safety Institute, in conjunc-

tion with the WHO’s SAVE LIVES: Clean Your Hands campaign. The day is celebrated annually on the fifth day of the fifth month, representing five fingers on each hand. The WHO slogan for May, 5, 2019 is “Clean care for all – it’s in your hands”. Calls to action have been created, targeted to each of these audiences: • Health workers: “Champion clean care – it’s in your hands” • Infection Prevention and Control leaders: “Monitor infection prevention and control standards – take action and improve practices” • Health facility leaders: “Is your facility up to WHO infection control and hand hygiene standards?” • Patient advocacy groups: “Ask for clean care – it’s your right” Planning is now underway to celebrate STOP! Clean Your Hands Day across the country on Monday, May 6, 2019. Visit www.handhygiene.ca to H learn how you can participate. ■

Anne MacLaurin is a Senior Program Manager with the Canadian Patient Safety Institute, leading the infection prevention and control national strategy.

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FEBRUARY 2019 HOSPITAL NEWS 23

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INFECTION CONTROL 2019

Face-to-face with infection prevention and control By Michael Oreskovich nfections are the most common kind of complication for hospitalized patients, responsible for thousands of deaths each year according to the Public Health Agency of Canada. Since their prevention is fundamental to patient safety and the recovery process, Runnymede Healthcare Centre has taken steps to strengthen its partnerships with patients and families by increasing access to the hospital’s infection control experts. Patients and families have always been able to rely on Runnymede’s infection prevention and control (IPAC) team to be there when they need support. In addition to providing in-person consultation upon admission, the team also arranges for pa-

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tient- and family-focused IPAC education at key points through the year, including at Canadian Patient Safety Week and IPAC Week events. But in late 2017, a new series of meetings was launched that took the team’s engagement with patients and families to a new level. Bimonthly Patient Family Engagement Committee meetings are held on every floor at Runnymede to give patients and families a chance to meet with hospital staff, and the IPAC team always takes part. “One of our goals is to increase our patients’ and families’ access to the IPAC team so they can share information about infection control and raise awareness about how important it is,” says Raj Sewda, VP of clinical operations and quality, chief

Setting a New Standard for Non-Antimicrobial Soap Performance There has been limited innovation in handwashing, with the largest advances being the advent of foam formulations and improved skin compatibility, i.e., mild formulations. However, there haven’t been major formulation advances in skin cleansing (i.e., removal of dirt, bodily fluids, microorganisms, etc.), the primary function of handwashing. GOJO has developed improvements in non-antimicrobial soap performance by optimizing the skin cleansing properties without sacrificing skin compatibility or aesthetics. PURELL HEALTHY SOAP™* with CLEAN RELEASE™ Technology sets a new standard for soap performance. • Remarkably mild formulation is gentle on skin • Contains no antimicrobial active ingredients or harsh preservatives1 • Removes more than 99% of soil and germs.1-3 PURELL HEALTHY SOAP™* with CLEAN RELEASE™ Technology is a superior non-antimicrobial handwash ideal for a high frequency hand hygiene environment such as healthcare.

To learn more on this new innovation from GOJO visit www.PURELLSOLUTION.ca *Cleans & Moisturizes 1. Does not contain an antibacterial soap active ingredient. 2. Augustine Scientific, Newbury OH, Ex Vivo Soil Removal Analysis, August 5, 2017. 3. BioScience Laboratories, Inc.; Bozeman, MT, Study# 170398-101, Evaluation of In-Vivo Germ Removal, July5, 2017.

26 HOSPITAL NEWS FEBRUARY 2019

THESE FACE-TO-FACE MEETINGS HAVE GIVEN THE IPAC TEAM A NEW FORUM FOR ENGAGING PATIENTS AND FAMILIES DIRECTLY ABOUT INFECTION PREVENTION. nursing executive and chief privacy officer at Runnymede. “The conversations we have at these meetings with patients and families have the potential to save lives.” These face-to-face meetings have given the IPAC team a new forum for engaging patients and families directly about infection prevention. “The best way to help patients and families understand the importance of infection prevention is through in-person education,” says Catherine Fitzpatrick, Runnymede’s director of flow, quality, pharmacy and privacy. “We see that when this happens, they’re more likely to adopt safe practices.” An example of this is with Runnymede’s annual flu shot campaign. Every September, the IPAC team raises patients’ and families’ awareness about vaccine safety, explains the risks associated with not getting the flu shot, and takes the time to listen and address their questions and concerns. Importantly, the team also gives patients an opportunity to consent to receive their flu shot at Runnymede, and advises family members on where they can go for vaccination. The efforts appear to be having a measurable impact. As of January 2019, 71 per cent of patients at Runnymede received the flu shot. According to a 2018 Public Health Agency of Canada report, this is nearly double the national rate for adults. (It helps that the hospital’s staff lead by example: since 2015/16, Runnymede has placed first or second among its peer hospitals in the Greater Toronto Area (GTA) for staff vaccination.)

The meetings also provide patients and families with a chance to offer their feedback on hospital policies and resources around infection prevention. “There’s no better way to evaluate the effectiveness of IPAC education than to get feedback straight from patients and families,” says Fitzpatrick. “Our patient- and family-centred approach often generates fresh new ideas and insights.” For example, family members with loved ones on contact precautions told the IPAC team that available information about putting on and removing personal protective equipment (PPE) didn’t meet their needs. In response, the team created new PPE instruction signage that contained the level of detail patients and families asked for, and ensured it was widely available on the patient floors. The IPAC team went further by flagging the issue for nursing staff so they were aware of family members’ need for extra support with PPE procedures. In addition to enhancing safety at Runnymede, the feedback gathered by the IPAC team also serves to improve the patient experience. To help protect patients if an outbreak is declared, the hospital may temporarily restrict the number of visitors to just one per patient. “Our patients told us this had a negative impact on their experience, and they asked if we could do something about it,” says Fitzpatrick. “Non-compliance with infection control procedures clearly wasn’t an option, so we had to dig deeper and be creative with the way we acted on this identified patient need.” Continued on page 28 www.hospitalnews.com

INFECTION CONTROL 2019

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C 2019. GOJO Industries, Inc. All rights reserved. | 27410 (1/2019) *Cleans and moisturizes 1. Does not contain an antibacterial soap active ingredient. 2. Augustine Scientific, Newbury OH, Ex Vivo Soil Removal Analysis, August 5, 2017. 3. BioScience Laboratories, Inc.; Bozeman, MT, Study# 170398-101, Evaluation of In-Vivo Germ Removal, July5, 2017.

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FEBRUARY 2019 HOSPITAL NEWS 27

Continued from page 26 The team connected with Runnymede’s activation therapy department, and a solution was developed: By facilitating Skype and FaceTime calls, Runnymede now enables patients to have virtual face-to-face interactions with loved ones when visiting is restricted, all while upholding the hospital’s commitment to safety during outbreaks. In-person access to Runnymede’s IPAC team members through the bimonthly meetings engages patients and families about infection prevention and underscores its impact on safety and the recovery process. “These meetings have sparked discussions about infection control that might never have happened if we hadn’t created an environment in which patients and families could meet with our IPAC team,” Sewda says. “This is another example of how Runnymede’s staff actively collaborates with patients and families to enhance their experience and make them true partners in H their own care.” ■

Bimonthly Patient Family Engagement Committee meetings at Runnymede Healthcare Centre are a forum for the hospital’s IPAC team to share information about infection control and raise awareness about its importance.

Michael Oreskovich is a communications specialist at Runnymede Healthcare Centre.

INFECTION CONTROL 2019 SPONSORED CONTENT

Revolutionizing human waste management and infection control in hospitals n today’s hospital environment, the patient experience, their health outcomes and the support of their professional care-givers has never been more important. One of the key areas within the hospital and health care setting that has, and remains a challenge, is the safe and efficient method of dealing with human waste. With mounting pressure on cost reduction, demands for increased efficiency and the need for improved infection control, the process of effectively dealing with human waste can put additional stress on nursing and care staff. Within the last century, a simple, yet effective way to combat these pressures, while delivering optimum care results has been achieved through the development of environmentally friendly, moulded pulp products and maceration disposal units. The pioneer and current leader in this field is Vernacare, who first introduced moulded pulp products and maceration units to the healthcare system. Vernacare brought the new biodegradable pulp product line made from 100% recycled post-consumer newsprint to the market in 1959 to replace the traditional method of human waste disposal via plastic or metal reusable bedpans, urinals, bowls and basins.

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SINGLE USE PULP PRODUCTS DRAMATICALLY REDUCE THE SPREAD OF INFECTION AND SAVE PRECIOUS NURSING TIME PREVIOUSLY SPENT ON UNPRODUCTIVE AND OFTEN UNSAFE MANUAL WASHING AND DISINFECTING OF REUSABLE BEDPANS, URINALS AND BASINS. This new product line revolutionized human waste methods by introducing single use, maceratable waste containers to the bedside. Single use pulp products dramatically reduce the spread of infection and save precious nursing time previously spent on unproductive and often unsafe manual washing and disinfecting of reusable bedpans, urinals and basins. To complement the advent of moulded pulp products and further enhance the human waste disposal system, environmentally friendly, compact and hands-free maceration units were added to complete the system. The maceration unit allows for the ultra-hygienic and efficient disposal of single use pulp products through the existing sewer system with minimal and in some cases no disruption to the existing plumbing configuration within the health care facility or hospital. Not

all maceration units can provide the assurance of minimization of particle size to ensure no dry or bulky material can pass into the pipework and causing disruptive clogs. Only Vernacare’s SmartFlow Technology can deliver this type of efficiency. Single-use containers and maceration units are now common place in hospitals around the world, thanks to the dedicated product development innovation focus of Vernacare. Other critical factors to consider and ensure successful implementation of this type of human waste disposal system are the ongoing training, support and supply chain effectiveness of your supplier. Selecting a supplier who has singular control from product manufacturing through to distribution and servicing of the products and system ensures the highest quality and reliability of this critical function. Again, Vernacare has the

only moulded pulp factory in the world that is exclusively dedicated to the manufacture of medical grade products and their comprehensive training and service support is unparalleled. Downtime in human waste management is simply unacceptable. By working with the only end to end supplier in human waste systems, health care facilities can enjoy the benefits of improved infection control, assured excellence in material quality, better use of nursing resources, and improved efficiencies all resulting in enhanced patient experiences and cost control. The industry has been well served by Vernacare in their dedication to this vision, as the originator and leader in the field of human waste systems. The healthcare and patient care sectors are experiencing rapid evolution and change. Vernacare is an organization that is a trust partner known for delivering uncompromised quality and service support. Excellence in patient outcomes and staff morale depend on the quality of care often contingent on products that facilitate wellbeing and positive, reliable results. This objective is well served and understood by Vernacare, the global leader and innovator in human waste management H systems. ■

FEBRUARY 2019 HOSPITAL NEWS 29

INFECTION CONTROL 2019

Early report:

Flu vaccine providing substantial protection against influenza this year he 2018/19 influenza vaccine is 72 per cent effective against the H1N1 kind of influenza A virus that is dominating this year’s flu season in Canada. The vaccine is offering much better protection than recent years, according to the mid-season analysis performed by the Canadian Sentinel Practitioner Surveillance Network (SPSN). The SPSN is a network headquartered at the BC Centre for Disease Control (BCCDC) that measures how

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well the influenza vaccine works every year. Those estimates are based on specimens and data submitted by hundreds of general practitioners from patients presenting with flu-like illness. The network operates in the four largest provinces of Canada: Alberta, British Columbia, Ontario and Quebec. “A vaccine effectiveness of about 70 per cent means for every 10 cases of influenza in unvaccinated people, the

number would have been reduced to just three cases if they had been vaccinated,” says Dr. Danuta Skowronksi, lead for the Influenza and Emerging Respiratory Pathogens Team at the BCCDC and the lead of the Canadian SPSN. “That’s an important reduction in risk, especially for people with underlying medical conditions who face a greater threat of serious complications if infected by influenza.”

both H3N2 and H1N1 influenza A viruses, as well as influenza B, which may make an appearance later in the season. “Vaccine effectiveness in general tends to be better against H1N1 viruses than the other kind of influenza A, called H3N2,” says Dr. Skowronski. “This year’s vaccine performed well in part because the H1N1 kind of influenza A virus has been dominating and

In addition to vaccination, there are other steps people can take to reduce their own risk and minimize the spread of viruses to others. This includes: ■ Wash your hands frequently especially if you’ve been out in public. ■ Avoid touching your face, especially your eyes, mouth and nose. ■ Cough and sneeze into your elbow. If you use a tissue, make sure to dispose of it properly and wash your hands. ■ If you feel unwell, stay home so you don’t pass your infection onto others, especially those who may be at higher risk. ■ If you are in close contact with people at higher risk of serious complications from influenza, get the vaccine and don’t visit them if you feel unwell. The H1N1 virus tends to have a greater effect on children and non-elderly adults, whereas the H3N2 virus tends to be harder on the elderly. The vaccine affords protection against

30 HOSPITAL NEWS FEBRUARY 2019

because this year’s vaccine is a good match to that circulating virus.” The vaccine effectiveness results were published online in the journal H Eurosurveillance. ■

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ASEPTIC RE FO CEDURE BE RO P

BEFORE INITIAL PATIENT/PATIENT ENVIRONMENT CONTACT

AFTER PATIENT/PATIENT ENVIRONMENT CONTACT

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Shedding light on ultraviolet disinfection for infection prevention:

A new wave of cleaning techniques? By Barbara Greenwood Dufour and Sarah Garland hen we go to the hospital for treatment, we expect to leave healthier than how we arrived. However, each year, more than 200,000 Canadians acquire an infection during their hospital stay. These acquired infections often mean more antibiotics are needed and hospital stays are longer. And about 8,000 patients die per year as a result of a hospital-acquired infection. Hospital-acquired infections can be caused by contact with contaminated surfaces. Pathogens – germs that are capable of causing illness – can commonly be found on chairs, bedrails, over-the-bed tables, curtains,

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and medical equipment. But they can be found anywhere in the hospital. One possible route of transmission is through droplets suspended in the air. Pathogens can become airborne and then settle on surfaces; when a contaminated item is moved, the pathogens can spread and contaminate new surfaces after they settle. Some pathogens don’t have to exist in high quantities to present a high risk of infection. Examples of these include microorganisms that are highly resistant to antibiotics, such as vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA), and pathogens that can cause severe illness, including

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Clostridium difficile, Acinetobacter baumannii, and Pseudomonas aeruginosa. To reduce the infection risk, hospitals have cleaning and decontamination protocols in place, which traditionally have included the manual cleaning of rooms where patients known to have these pathogens have been.

the research on drugs and medical devices. A 2014 CADTH review, which looked at non-manual disinfection in a variety of health care facilities, found low-quality evidence from one cohort study suggesting that UV light might be effective for reducing the incidence of hospital-associated C. difficile infections. However, it also uncovered two

SOME PATHOGENS DON’T HAVE TO EXIST IN HIGH QUANTITIES TO PRESENT A HIGH RISK OF INFECTION. These rigorous cleaning and disinfection measures, even though they are resource-intensive and costly, are not always effective at reducing infection rates to more acceptable levels. This may be because traditional, manual cleaning methods can result in the wrong choice of cleaning solution, the solution not being left on surfaces for long enough, and areas being missed. Non-manual disinfection devices have been suggested as a way to overcome the limitations associated with manual methods. These are intended to supplement, not replace, manual cleaning, which is still required to remove dirt and debris. One type of non-manual disinfection technology emits a specific intensity of ultraviolet (UV) light that is strong enough to destroy pathogens. UV disinfection devices have been proposed as an easy and efficient supplement to manual cleaning to reduce the rate of hospital-acquired infections. However, is there evidence that they do this? CADTH has produced a few evidence reviews of non-manual room disinfection techniques for infection prevention over the past few years. CADTH is an independent agency that finds, assesses, and summarizes

evidence-based guidelines concluding that there was insufficient evidence to make recommendations about the use of UV light decontamination methods. The following year, CADTH conducted another similar review that found some new studies – a retrospective study and a prospective study, both non-randomized – indicating that UV light room disinfection methods are effective at preventing or reducing infection in health care facilities. However, the limitations of these studies suggested that further research would be needed to confirm this conclusion. More recently, in October 2018, CADTH looked for any new studies on this topic. After reviewing the outcomes and findings detailed in the abstracts of these studies, CADTH produced a Summary of Abstracts report on what was found. Although it isn’t a comprehensive review of the studies and CADTH hasn’t critically appraised the evidence, it gives us a broad sense of what the new research reveals, which is that the evidence continues to support the idea that using UV light room disinfecting devices can reduce the rate of hospital-acquired infections. Continued on page 35

32 HOSPITAL NEWS FEBRUARY 2019

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INFECTION CONTROL 2019 Cutline: MSH’s Corporate Services Department and Infection Prevention and Control Department are teaming up to create a safer, greener, cleaner MSH. (l-r) Maria Pavone, Director of Facilities and Support Services, Food Services; Nisha Punja, Manager, Infection Prevention and Control.

Creating a safer, greener and cleaner MSH By Andrew Aggerholm arkham Stouffville Hospital’s (MSH) Infection Prevention and Control Department (IPAC) and Corporate Services Department are teaming up to create a safer, greener and cleaner hospital. It’s vital that these two departments support and learn from each other to ensure the safety of MSH’s staff, patients and their families while also providing an excellent patient experience. A major component of this support is the education these two departments can offer each other. IPAC works closely with environmental services staff, patient transport and food services to educate them on infection control practices such as enhanced cleaning procedures, donning /doffing personal protective equipment and hand hygiene. “In the event of an outbreak I want to know why it happened and how we can prevent it from happening again,” says Maria Pavone, Director of Facilities and Support Services, Food Services. “We aren’t always able to implement IPAC’s solutions immedi-

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ately but we certainly work together to come to a mutual agreement on the best way forward. ” IPAC has also taken a more active role in supporting construction projects throughout the hospital. “Before we start any construction project, we work closely with IPAC to determine what type of protocols are required to protect our patients and staff,” says Pavone. “We have a construction matrix we follow as outlined by the Canadian Standards Association (CSA) which identifies the population at risk and the type of work that needs to be completed. Based on that information, we devise a plan for preventative measures,” says Nisha Punja, Manager, IPAC. “We also work to educate the vendors about the importance of IPAC while they’re working here.” These preventative measures include how the space will be prepared for the construction, whether hoarding and/or an anteroom is required and, at a minimum, these measures must be initiated to ensure patient safety throughout the project.

By working together, the two departments identified opportunities to reduce waste and the mess created by construction hoarding. When construction hoarding is required, current CSA standards indicate for it to be built with gypsum board, which generates dust when it’s cut onsite, needs to be stored properly in moisture free environments and discarded once it’s damaged. Additionally, because it’s a porous surface it can’t be cleaned readily and/or reused in future projects. MSH decided to look for alternatives to this type of hoarding that would address these pitfalls. In December 2018, MSH tried using a prefabricated containment system for its hoarding. “Because this product is prefabricated it doesn’t generate the same mess that gypsum board does especially during tear down. It meets the Infection Control Risk Assessment (ICRA) requirements for hoarding and dust mitigation. Since it’s not porous we can clean it as per manufacturer’s instructions and reuse it for other construction projects in various patient

care areas throughout the hospital,” says Punja. This means that less waste is being put into the landfill after construction and the work site is cleaner, which is important as it’s often close to patient care areas. The hospital first used this new hoarding during renovations in one of its operating rooms (ORs) and continues to trial the product at this time. “As part of our green innovation energy project we were installing sensors in our ORs that monitor temperature, pressure, air changes per hour and relative humidity in the room. In a sterile environment like that, keeping construction mess to a minimum was really important. The other advantage was that it reduced the cleaning time significantly, which allowed us to get the OR back into use faster,” says Pavone. As the relationship between the two departments continues to grow, both Pavone and Punja will continue to look for ways to collaborate and improve upon the ways MSH provides safe, environmentally friendly, high quality care to its patients, their famH ilies and the communities it serves. ■

Andrew Aggerholm is a Communications associate at Markham Stouffville Hospital. 34 HOSPITAL NEWS FEBRUARY 2019

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cleaning techniques? Continued from page 32 The studies included a health technology assessment of portable ultraviolet light surface-disinfecting devices, a systematic review and two non-randomized studies of no-touch ultraviolet light disinfection methods, a non-randomized study of a UV disinfection robot, and two non-randomized studies of a UV disinfection strategy. All of these studies conclude that UV technologies reduce the incidence of hospital-acquired infections. However, a more detailed review is needed to determine the quality of the evidence and provide a better understanding of how well these methods work. UV devices certainly won’t replace manual cleaning, and they may be better used in specific situations – such as to thoroughly clean a room after a patient infected with a known pathogen or colonized with it (having the pathogen but not showing signs of illness) has

been staying there. However, this type of non-manual UV room disinfection technology continues to show promise for

preventing hospital-acquired infections. If you would like to learn more about CADTH, visit cadth.ca, follow

Barbara Greenwood Dufour and Sarah Garland are Knowledge Mobilization Officers at CADTH.

us on Twitter @CADTH_ACMTS, or speak to a Liaison Officer in your H region: cadth.ca/Liaison-Officers. ■

LONG-TERM CARE NEWS

Nutrition and dementia in long-term care By Dale Mayerson and Karen Thompson ccording to the Alzheimer’s Society of Canada, 564,000 Canadians are currently living with dementia and the number is expected to rise to 937,000 by 2030. Dementia can affect the senses and can disrupt all of a person’s usual thoughts and activities. Providing meals to residents with dementia presents a number of challenges that staff needs to learn to recognize and to overcome. Alzheimer’s Disease is the most prevalent type of dementia, but there are others as well. Vascular dementia can be caused by blockage or damage to the brain’s blood supply; this could be the result of stroke or diabetes. Frontotemporal dementia can affect specific lobes of the brain that are associated with personality and behaviour. Lewy-body dementia interrupts the brain’s message system and can affect thinking and movement. It is also possible to have several dementias presenting in an individual. The disabilities of the individual vary with the degree of dementia, but the Alzheimers’ Society has summarized the disabilities as the 7 As of Dementia: • Anosognosia – don’t recognize disability • Agnosia – no longer recognize senses • Aphasia – can’t speak or understand • Apraxia – no purposeful movement • Altered perception – no message from senses • Amnesia – loss of memory • Apathy – no drive or initiative

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DEMENTIA IN LONG-TERM CARE According to the Canadian Institute of Health Information (CIHI), in long-term care homes, 69 per cent of residents had dementia in 2015–2016. Of those residents with dementia, 92

per cent required extensive assistance or are dependent for activities of daily living; 50 per cent had responsive behaviours due to the inability to communicate; 31 per cent had signs of depression and 40 per cent had severe cognitive impairment. Activities of daily living include being able to groom, dress, bathe and feed oneself. Staff provides a significant amount of assistance and supervision to support residents with dementia in their daily lives according to the needs of each individual. Residents with dementia may become easily frustrated by their inability to communicate, to find their way or to complete the activities of daily living. Some homes have “locked” units that may have an increased staffing level and provide a more secure environment. Long-term care homes generally have programing that helps staff to successfully interact with residents who have dementia, including those who may be aggressive with other residents and/or staff. These programs are developed in concert with residents, families and experts such as staff from Behaviour Supports Ontario and the Alzheimer’s Society. The physical layout of a long-.term care home, and the colours and art used in the living environment can improve a resident’s ability to cope or it may make it worse. The manner in which staff approaches residents with dementia can significantly affect residents’ behaviours and their day to day activities. New approaches from around the world are being considered and tried, such as the recent Butterfly Household Model of Care that originated in England.

CHALLENGES WITH FOOD INTAKE Residents with dementia may have multiple challenges with eating. They may not recognize food when it is

36 HOSPITAL NEWS FEBRUARY 2019

PROVIDING MEALS TO RESIDENTS WITH DEMENTIA PRESENTS A NUMBER OF CHALLENGES THAT STAFF NEEDS TO LEARN TO RECOGNIZE AND TO OVERCOME.

served or they may not remember how to feed themselves. Swallowing may be affected and residents may require careful staff assistance with eating. Residents may be unable to sit for any period of time to eat their meals course by course, and may manage better by receiving all their courses together. Homes may offer “finger foods” that allow residents to eat meals and snacks while wandering or pacing. Food intake is often less than ideal and fortified food items may be helpful to boost intake. As well, high protein snacks or liquid nutritional supplements may be offered to provide extra protein and other nutrients. Home staff focuses on retained abilities, ensuring that residents eat as independently as they are able, perhaps with staff encouragement and cueing. Assistive eating utensils are available that support independence for those with specific eating issues. Allowing residents with dementia to make food choices may encourage better food intake. Offering smaller, more frequent portions of food is another strategy that successfully increases the amount of food eaten for some individuals. Some research has shown that serving meals on brightly coloured plates also encourages residents to eat more. Further, offering favourite foods at the time of day when a resident eats the best is another way to encourage optimum intake. This could be discussed with family who know the resident’s history and eating habits the best.

DIET AND DEMENTIA In most cases, the goal for residents with dementia is to liberalize the diet which means reducing unnecessary food restrictions in an effort to maximize quality of life. This has the benefit of increasing the variety of food available at meals and snacks, which may therefore result in an increased nutrient intake. Since most residents have more than one medical diagnosis, careful consideration is required in determining dietary needs. For example, a resident with dementia can also have diabetes, high blood pressure, osteoporosis, and constipation. The need for nutritional support, such as increasing calcium for bone health, monitoring carbohydrates for diabetes and maintaining sodium and boosting fibre intake, are all considered in light of the dementia. The dementia may alter the risk-benefit balance in this decision making. Concerns with poor food and fluid intake can include: • Confusion due to dehydration, which can also lead to falls • Sarcopenia, or muscle loss, leading to overall body weakness • Inability to taste the food leading to greater risk of malnutrition • Poor calorie intake leading to lack of energy • Poor fibre and fluid intake leading to constipation that the resident is unable to report • Difficulty chewing that may not be immediately recognized by staff, which may lead to choking incidents www.hospitalnews.com

LONG-TERM CARE NEWS

• Significant weight loss over longer periods of poor food intake • Weight loss can lead to bone loss in jaw and poorly fitting dentures • Greater caloric needs for residents who wander throughout the day • Anemia due to poor protein intake • Poor body positioning at meal leading to increased risk of coughing, choking

KEYS TO SUCCESS Collaboration among staff is important for successful interactions in the dining room with residents with dementia. Staff monitors residents at meals and snacks for food and fluid intake and shares this information with other care team members. An individualized diet plan is developed for each resident, and staff provides support in

a manner that is individualized and as creative as possible to encourage optimal intake.

Family can offer insights into resident food likes and dislikes, and the best times to increase food intake. Quality of life

and resident satisfaction are the driving concerns for dining teams when planning H care and service in long-term care. ■

Dale Mayerson, B Sc, RD, CDE, and Karen Thompson, B A Sc, RD are Registered Dietitians with extensive experience in Long-term care. They are co-authors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians in Canada.

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Designing for cognitive well-being By Monica Fleck magine you’re a third-year college student in an interior design program and you’ve just completed six weeks of observing how long-term care residents with dementia interact with their living space. Now you find yourself presenting your recommendations to the architect who actually designed the facility and the CEO who oversaw the build. That was exactly the experience this fall for 25 students in the Interior Design Program at Fanshawe College who were given this unique learning opportunity through the collaboration of Professor Natalie Rowe of Fanshawe’s Faculty of Art, Media and Design; Richard Hammond, architect at Cornerstone Architecture; and Steven Crawford, CEO of McCormick Care Group, the governing organization of McCormick Home, a long-term care facility in London, Ontario.

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“It was really interesting and a bit nerve-wracking,” says Fanshawe student Christine Belanger of the presentation experience. But as it was the first time she was able to interact with the people living in the study space, she found that the positive experiences outweighed any apprehensions. “The project helped me to understand that we are designing for real people and not for hypothetical clients. It was heartwarming to put a face to the work.” “It’s definitely not just about physical design – this project gave us the opportunity to look at the space from a human-centric point of view,” she adds. The students were asked to observe the daily living activities of people with dementia and how they interact with their surroundings in five particular areas – dining rooms, recreation spaces, bathing areas, nursing stations and wayfinding. The students were asked

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to identify improvements that could be made at McCormick Home’s current building, which opened in 2006, as well as provide recommendations that could be used in the construction of new facilities. “This project really opened my eyes to how design can genuinely support peoples’ health and well-being. I enjoyed the freedom to learn by experience,” says student Lauren Hylands. One team summed up the research philosophy in this way: “The psychological framework of a human is so complex and delicate, our direct surroundings heavily impact not only our physical comfort, but also our mental well-being.” This approach helped to guide the sensitivity involved in seeing the living environment from the perspective of someone who is facing cognitive challenges. “Being able to interact with people in real life and not just research online was a great learning experience,” says student Breymann Welch-Clark. While some groups focused on more major renovations such as adding or removing walls, others focused on finer design details such as lighting, finishing materials and colour. For example, enhancing privacy and introducing vanities and storage spaces more reminiscent of home would help improve the bathing experience for the residents and the staff providing their care. Replacing traditional serveries with open kitchens and breakfast bars would enhance the olfactory, visual, auditory and tactile experience. Another group eliminated

nursing stations in favour of using mobile technology to repurpose the space for residents and families. Common themes emerged from all teams, including creating an environment that is more home-like and nature-oriented, and one that is designed to stimulate the human senses and optimize the residents’ experience of interacting with their surroundings. “The students’ design ideas were very innovative. I liked the range of recommendations, which varied from broad to specific,” says Hammond. Other layout and design suggestions include: • Maximizing the amount of window space to connect with the outdoors • Using Smart Screens to project images that trigger pleasant memories, promote visual stimulation and provide recreational opportunities • Projecting sounds of waterfalls or waves on a shore to create a relaxing atmosphere • Displaying nature scenes in photos and artwork • Building recessed benches along the hallways where people can stop and rest • Using matte finishes and warm colours for lounge areas and stronger colours to assist in area recognition and wayfinding • Building rounded corners on fixtures and counters to improve the visual flow of the space and enhance safety • Creating more defined social spaces for resident and family visits The recommendations across all five areas demonstrated a thoughtful and www.hospitalnews.com

LONG-TERM CARE NEWS This nursing station redesign concept demonstrates the use of curved lines and a naturethemed wall mural. Left: This design demonstrate an open-concept kitchen with defined social spaces to enhance social connection and stimulate the sensory experience.

compassionate approach to enhancing quality of life and making the most out of a resident’s abilities, according to Rowe. “The time students spent at McCormick Home resulted in an attachment not only to the building, but to the staff and residents. There were

spontaneous activities and experiences that cultivated a level of curiosity and empathy for the journey the residents were on. As a result, the design solutions came from a place of passion and desire to make the world of long-term care a better place for everyone.”

“The creativity and professionalism demonstrated by the students far exceeded my expectations,” says Crawford. “When we talk about intergenerational programming within long-term care, we often think of younger schoolaged children. These college students

offered us a new level of engagement with our residents, bringing their particular expertise and perspectives to help the needs of a different generation.” For more information, please contact Steven Crawford at scrawford@ H mccormickcare.ca. ■

Monica Fleck works in communication at McCormick Care Group.

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FEBRUARY 2019 HOSPITAL NEWS 39

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It’s a voice forward world: impacting digital health By Mary Lou Ackerman ngaging people in health means we need to make health more engaging. This year’s Consumer Electronics Show (CES) in Las Vegas (January 8-11 2019) had a dedicated Digital Health stream that showcased new and innovative technology for the future of health.

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FROM HOSPITAL-TO-HOME This year marks a transition from the “connected age” to the “data age”, moving from “Internet of Things” to “Intelligence of Things”, a real enabler of the notion of healthcare anywhere! For a number of reasons well beyond lower cost of care – i.e. improved health outcomes, more convenience, and decreased cognitive impact – the shift from hospital or clinic to the

home for healthcare service delivery was a common thread throughout the Digital Health Summit. As the population continues to age, entrepreneurs are zooming in on personalized, smart, voice-enabled tools to empower people and families with new capabilities that were previously not easy to access, such as schedule management, remote monitoring health, cuing, 24/7 companionship, and convenience and control. The data collected from these types of technologies can also be used to predict changes in normal behaviors leading to early intervention or “right time” interaction with targeted, proactive health services based on predictalytics algorithms.

LEAN IN ON VOICE The adoption rate of voice interfaces such as Amazon’s Alexa and Google

40 HOSPITAL NEWS FEBRUARY 2019

Home in the US has surpassed that of the smart phone. With almost 30 per cent of all homes in the US currently owning at least one of these devices, and a 78 per cent increase in adoption this past year, voice-enabled tech is now entering the digital health space at an incredible pace. Health consumers are beginning to endorse voicebased healthcare technologies. Given healthcare consumers’ zero tolerance for complexity, voice-based tools that use existing household platforms such as Alexa and Google Home are breaking down this adoption barrier by providing a meaningful easy to use interface. These smart speakers (often referred to as digital assistants) have omnipresence in your home, always ready when called upon. They offer the flexibility the traditional smart home monitoring

does not. For example, depending on their needs, seniors can personalize the types of interactions they want to have with their digital assistant without having it “always on” but know that it is “always there” when you need it by simply saying its name or programming it to interact with you when you want it to. “Always there” versus “always on” removes the barrier of feeling like there is constant surveillance, something which is not always welcomed by people as they age at home.

INSIGHTS ABOUT ADOPTION: PARTNERSHIPS, AWARENESS AND EXCELLENCE As emerging voice technologies infiltrate into the healthcare space, a number of key considerations were www.hospitalnews.com

LONG-TERM CARE NEWS

shared by leading innovators and practitioners at the Digital Health Summit: Although voice-based digital assistants can provide support and identify changes in behavior, they cannot close the loop and actually provide care. They can, however, identify when health care services may be needed. To get the full benefits of the digital assistant + human service provider will require creative partnerships between retailers (distribution to consumers), health technology companies (makers of the voice tech) and health service providers (source of humans that are trained to deliver warm care). Joining these three actors in new partnerships will require the design of innovative service delivery models that provide the right care at the right time, at the right price. Often these models will include a care team that include informal family caregivers as an integral member of the team. Adoption lesson learned: Lean in on Partnerships

Although there is increasing evidence of the value that the smart speaker digital assistant can bring, especially to seniors who are living alone, the adoption of this type of technology continues to be slower with this demographic. Awareness of the technology, its functionality and value in general is poor, not only with consumers but with health professionals as well. Health consumers look to their health providers for recommendations to improve or better manage their health. Health providers are the enablers to drive adoption and need to be informed of its availability and value. Adoption lesson learned: Lean in on Awareness Finally, as the digital assistant is “always there” it is critical that it always works! If we are going to depend on technology to assist in the management of our health, consumers will not tolerate disrupted service. It must work all the time, people’s lives de-

pend on it. Adoption lesson learned: Lean in on Excellence. Walking the exhibition floors at CES is quite an experience that anyone bringing innovation in health and care should experience at least once in their career! There is no shortage of emerging technologies that are positioned to change nearly every facet of how we live our lives and manage our health – super smart homes, robots, flying cars, autonomous mobile clinics, digital therapeutics, virtual reality, augmented reality, and so much more. It’s hard not to be optimistic about the future of health (care). But with a heavy dose of caution – techno-optimism for technology’s sake is not at all the answer to address the unmet needs of so many patients and families. As we embrace these emerging voice and other technologies it will be paramount to also share our adoption and impact stories similar to those shared H this year at CES. ■

Mary Lou Ackerman is Vice President of Innovation, SE Health.

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LONG-TERM CARE NEWS

Helping long-term care physicians provide better care By Dr. David Kaplan and Anna Greenberg ince 2015, Ontario family physicians who provide medical care to residents of long-term-care homes have been able to receive confidential, personalized reports on how to improve their practice. To date these quarterly reports – known as MyPractice: Long-Term Care reports and produced by Health Quality Ontario – have focused on the priority area of optimizing the use of antipsychotic medications and benzodiazepines and addressing the particular risks associated with some of the medications (e.g. falls). Health Quality Ontario collaborated with Public Health Ontario in the development of antibiotic prescribing indicators and ideas on how physicians can improve their practises. In addition, the reports contain contextual data on resident demographics, behavioural characteristics, and chronic conditions. Health Quality Ontario will soon expand the scope of the reports to include antibiotic prescribing data. These much-anticipated indicators will allow long-term care physicians to see how many of their residents have been started on antibiotics and how often their prescription duration is longer than seven days – which may not be necessary for common uncomplicated infections found among LTC residents. Appropriate prescribing of antipsychotics and antibiotics in long-term care homes have been singled out by the Choosing Wisely Canada initiative as one means of reducing unnecessary tests and treatments among long-term care home residents. However, there is also a recognition that there are times when these medications are needed. The My Practice reports are meant to optimize care, not just reduce the medications. The reports also allow physicians to compare their prescribing practices with their peers at the regional and provincial level and they provide tools

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SO FAR, MORE THAN 400 PHYSICIANS HAVE SIGNED UP TO RECEIVE THE MYPRACTICE LONG-TERM CARE REPORTS. and topic-specific resources for improving quality care. So far, more than 400 physicians have signed up to receive the MyPractice Long-Term Care reports. In Ontario, there are approximately 800 physicians with a substantial LTC practice. To demonstrate the value of the reports, Health Quality Ontario quotes the case of Dr. Julie Auger, Medical Director of Golden Manor Home for the Aged in Timmins, Ontario, Medical Director of Continuing Care Rehabilitation Programs at Timmins and District Hospital, and Board Member of the not-for-profit organization Ontario Long Term Care Clinicians. From her MyPractice: Long-Term Care reports, Dr. Auger saw that 178bed Golden Manor averaged an overall antipsychotic prescribing rate of 40 per cent in 2015, which was much higher than she had expected. Motivated to set an example for the sector, she was determined to make some changes.

After reviewing all of her residents’ files and confirming each of their diagnoses, Dr. Auger realized that there was quite a bit of misclassification (mislabelled drugs or indications, incorrect diagnoses) in her patients’ charts and the nursing home’s coding database. After cleaning up files and educating staff at the home on the importance of accurate documentation, by the fall of 2015 Dr. Auger found that her overall rate of antipsychotic use was 35 per cent: with 15 per cent being deemed to be appropriate while the remainder involved “inappropriate” prescribing. As Dr. Auger described, “I must admit, it was easy to generate all sorts of excuses as to why my numbers were justifiably high. But when I really started digging into it… one of the biggest barriers in getting them down had been my own inertia and just lack of time and energy to focus on it.” After making changes to improve

the process of prescribing, Dr. Auger found the rate of “inappropriate” antipsychotic prescriptions dropped to about 10 per cent in a year. Work has been ongoing to evaluate the impact of the reports overall. Unpublished data from a team of independent researchers from Women’s College Hospital and ICES, has shown a statistically significant reduction in prescribing anti-psychotics among those who received the report, and a further reduction for those who opened their report. MyPractice:Long-Term Care reports were one of the tools used as part of the Appropriate Prescribing Demonstration project – a partnership between Health Quality Ontario, the Ministry of Health and Long-Term Care, the Ontario Medical Association and the Centre for Effective Practice aimed at prioritizing appropriate prescribing of antipsychotics in most long-term care homes across Ontario. Data show the percentage of long-term care home residents given antipsychotic medications in the absence of documented psychosis fell to 20.4 per cent in 2016/17 from 22.9 per cent in 2015/16. This was according to Measuring Up, Health Quality Ontario’s annual assessment of the province’s health care system, which notes it is a trend that has been continually improving over the past 6 years. MyPractice: Long-Term Care reports were developed by Health Quality Ontario with the support of ICES and in partnership with the Ontario Medical Association, Ontario Long Term Care Clinicians, Ontario Long Term Care Association, AdvantAge Ontario, the Nurse Practitioners’ Association of Ontario, the Ontario Pharmacists Association and Public Health Ontario. The reports are also developed with ongoing input from family physicians who work in longH term care. ■

Dr. David Kaplan is Chief Clinical Quality and Anna Greenberg is Interim President and CEO of Health Quality Ontario. 42 HOSPITAL NEWS FEBRUARY 2019

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LONG-TERM CARE NEWS

Green Hospital Scorecard expands By Linxi Mytkolli he Green Hospital Scorecard (GHS) will be offered again this year to hospitals across Canada by the Canadian Coalition for Green Health Care. This will be the sixth year of the GHS, which is the only environmental and sustainability benchmarking tool of its kind in Canada, providing a snapshot of a hospital’s performance in energy and water conservation, waste management and recycling, corporate commitment, and pollution prevention. Participating facilities report on their environmental and sustainability initiatives through an online questionnaire. Every participating hospital receives an individualized scorecard which summarizes their environmental performance from year to year and relative to their peers. The intent of the

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PARTICIPATING FACILITIES REPORT ON THEIR ENVIRONMENTAL AND SUSTAINABILITY INITIATIVES THROUGH AN ONLINE QUESTIONNAIRE. scorecard is to raise the hospital organization’s awareness, motivate change, and incite improvements in the environmental sphere by recognizing each participating hospital’s achievements. Senior management have been using their scorecards to assess progress and plan next steps thereby achieving environmental and economic benefits such as reduced greenhouse gas emissions and improved energy and water efficiency. Participation in the program is free.

In addition to the scorecards, participants are recognized individually with bronze, silver and gold achievements, as well as through the annual Green Health Care awards. Each year, the program culminates with a webinar to celebrate the award winners and their achievements in sustainability. Winners share their stories and showcase best practices and the latest innovations in the field. The program has grown tremendously over the past five years, with

over half the hospitals in Ontario now participating in the survey, as well as respondents across different provinces and countries too. We are pleased to announce that the GHS will be expanding this year to include several brand new sections, including energy behaviour, food, transportation, and climate change. Thanks to the generous support of our energy sponsor SaveONenergy, a new Energy Behaviour Award will also be offered. The Coalition will be offering free educational webinars for participants to learn more about the new sections of the survey and to support them in their completion of this year’s program. For more info on the GHS, and how to participate, please visit our website greenhealthcare.ca/ghs or contact the H Linxi at linxi@greenhealthcare.ca ■

Linxi Mytkolli, GHS program manager, Canadian Coalition for Green Healthcare. She can be reached at linxi@greenhealthcarte.ca

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NEWS

Clinical Engineers: An untapped resource C

linical Engineers (CEs) are professionals who bridge the gap between clinical users and medical technology with cultivated cross-disciplinary skills. This is a role that has been developed in North America over the last 40 years. The evolution of medical technologies has surpassed the capability of most healthcare practitioners; so much that healthcare facilities may be overwhelmed by the management of clinical technology. Q: What type of work does a Clinical Engineer perform? A CE has a subspecialty in engineering management technology and is clinically accustomed to handle medical equipment decisions among other responsibilities (See Figure 1). The scope of medical technologies that CE’s are able to deal with range from infusion pumps to MRIs. Clinical Engineers need to be involved in decisions regarding medical technology as they have the ability to fully embody the project from start to finish. Q: What added value can a Clinical Engineer bring in my hospital? In the current fast-pace evolution of healthcare technology, CE’s are its stewards. They easily translate clinical needs into technical requirements to uphold the hospital’s standard of patient care and quality. CE’s can also communicate effective strategies to enhance technology management to hospital administrators. They collaborate with others, to work towards the advancement of healthcare quality, patient safety, process reliability, healthcare availability, speed and efficiency of healthcare delivery, and cost effectiveness of process. Q: What value does a Certified Clinical Engineer (CCE) bring to our organization? Certified Clinical Engineers (CCEs) already standalone as they are degreed engineers which changes their approach towards problems from other individuals. Certification shows that a Clinical Engineer is not only competent, but passionate in their field. The Certification Program is run by the

Clinical Engineers making a difference with the neonatal transport incubator. From left, Kim Greenwood, Marie-Ange Janvier and Rachel Zhang.

Summary Of CE Skills ✓ Ongoing management of technology - intensive organization, healthcare technology and personnel ✓ Establishing tighter communication of systems for diagnosing information - processing and treatment ✓ Cross collaboration, (contractors, clinicians, etc.) to progress daily work ✓ Managing resources: instruments, funds or personnel ✓ Ensure compliance with Health Canada regulations - mandatory reporting. Medical devices licenses ✓ Analysis of processes to make improvements ✓ Requirement for documentation of policies, procedures and work logs. ✓ Managing medical device alerts and health reports ✓ Assure demands are met and correct actions are taken

Figure 1 Healthcare Technology Certification Commission with a United States and Canadian Board of Examiners. Prior to applying to become a CCE, in Canada, individuals must become a Professional Engineer which makes the individual duty-bound to a higher directive. Over and above just being a manager of equipment, Professional Engineers have a moral and legal obligation to ensure patient safety, ethical practice, and a duty of care to the public. The certification ensures lifelong learning becomes a part of a Clinical

Engineer’s career. In order to keep certification, triennial renewals verify continual personal and professional growth, and that CE’s maintain their acquired skills. Q: What is the fundamental difference between Clinical Engineers, PMPs and CHTMs? When consulting problems CEs have a vastly different approach than CHTMs and PMPs; CEs are trained to understand things at a system engineering level through first principle approaches while CHTMs and PMPs operate at a broader understanding.

Clinical Engineers have the depth of experience and education to evaluate hospitals risks which is how they develop innovative solutions and are able to expedite decisions. Q: What are healthcare professionals saying about Clinical Engineers? “We are fortunate to have the involvement of CEs in increasing our effectiveness in care delivery through capital priority setting exercises and quality improvement projects. One recent project highlighted the importance of the CE role in overhauling the standard equipment needed for each patient’s bedside on our inpatient units. We are very grateful to our CEs for their invaluable assistance on this specific project and many other capital renovations throughout the hospital.” Ann Lynch, Vice-President, Acute Care & Chief Nurse Executive at the Children’s Hospital of Eastern Ontario (CHEO) “CEs at CHEO has been instrumental in many projects throughout the Medical Imaging Department. With the recent acquisition of the 3T magnet, CEs have played an active role in the decision making, purchase and implementation of this technology. With the continuing evolution of technology, the CEs have been fundamental to our department. Our close relationship and collaboration assures our Medical Imaging team with equipment that remains optimal for serving our patients. “ Dr. Elka Miller, MD, FRCPC Chief and Research Director at the CHEO Medical Imaging Department Q: Where can I find out more information on CEs? A: Clinical Engineers can enhance your hospital’s performance in delivering patient care with technology. It is time to seek Clinical Engineers for your team, and preferentially Certified Clinical Engineers. For more information on Clinical Engineering please contact The Canadian Medical and Biological Engineering Society (CMBES) at H www.cmbes.ca ■

This article was submitted by Elese St.Louis, Marie-Ange Janvier PhD, P.Eng., CCE, Andrew Ibey M.Eng., P.Eng., CCE and Kim Greenwood MASc., P.Eng, CCE, FEIC. 44 HOSPITAL NEWS FEBRUARY 2019

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Continued from page 14 And finally, the reverberations of energy in my heart as I carefully cleaned the bodies of those babies while silently chanting: “I’m sorry. I’m sorry. I love you. I’m sorry.” I’m learning to make space for these memories and how they fit into my normal, very privileged life, but there are certain things that I struggle to reconcile. Nothing I do can make up for, or even begin to fix the incredible injustice of the fact that this happened in the first place. There was no memorial for three small children who died 80 years too young, a few hundred km’s from safety. No possibility of conveying to the parents how sorry, how desperately sorry I was, since their parents were lying in body bags next to them. In that moment there was mainly, I’m embarrassed to admit, startling numb-

ness and a desire to run as far away from that ship as I could. And part of me has been running ever since. So how do I, years later, find a way to honour those little lives the way they would have been if they had had the fortune of being born with the “right” colour skin or the “right” passport? How arrogant am I to even hope that I could? I wish I had an answer to this question; an easy one, a hard one, an incomplete one… I’d take anything. But nothing makes their death less brutal, painful or unfair. And perhaps truly accepting that is the only option. After months of processing, I am starting to feel power in the pain these memories bring. In the tears that are flowing down my cheeks as I write this

and the nausea and lightheadedness that wash over me with waves of sorrow and rage. Time after time the same phrase comes to me: I was there with them. There WITH them. We were there. But in the end, all we could be was present. And for the first time I see that there is a small shard of light in the dark moments I spent with these kids: I may not have been a witness to their beautiful, short lives, but I was a witness to their death and the pain of it lives in me. It’s not enough – not even remotely enough. I don’t kid myself. I cannot know their names, their favourite games, or even where they were from, but I know they were. I have the in-

credible honour of feeling the sorrow of their deaths that their parents, lifeless beside them, did not live to feel or carry. The pain is not pleasant, but I wouldn’t change that we were there – if only to bear witness to the fact that these children existed and the injustice that they no longer do. And if pain is the price we pay for that, the price we pay for knowing and acknowledging the intrinsic value of the thousands of lives that continue to be lived and lost on the Mediterranean then I will cherish it. I will not run from it. Rest in Peace to the tens of thousands of people who have lost their lives so senselessly in Libya and on the Mediterranean while European leaders stood by and watched. We will not forH get you and we will not be silent. ■

New technology detects abnormal heart rhythms By Meredith MacLeod everly Herridge, 82, was preparing for a knee replacement when she was told she needed surgery to repair a leaky aortic valve that was taxing her heart. Doctors at Hamilton Health Sciences’ Hamilton General Hospital (HGH) performed a minimally invasive transcatheter aortic valve implantation (TAVI) in July 2017. Beverly was under conscious sedation while a surgeon used an X-ray to guide a catheter inserted in her groin. When it reached her heart, doctors inflated a balloon to remove the degenerated valve and guide a new valve into place. “TAVI is a highly effective alternative to open-heart surgery for medically frail patients or those with complicating factors,” says Dr. Madhu Natarajan, site director for cardiology at HGH. Open-heart surgery is done under a general anesthetic and requires stopping the heart and placing the patient on cardiopulmonary bypass. Patients are hospitalized for five to 10 days.

B

HGH surgeons performed 1,731 TAVIs last year, with three-quarters of patients going home just one day after surgery. Beverly recovered in hospital for just a few days before agreeing to go home wearing a portable heart monitor so that doctors could track her heart function remotely. “I felt better in my own surroundings and that freed up a bed,” says the Burlington resident. “I am a worrier, but I wasn’t worried about that. I felt good they were watching me.”

The remote monitor collected round-the-clock data that nurses and doctors examined several times daily. It showed a concerning arrhythmia in Beverly’s heart, a complication that affects about 20 per cent of TAVI patients. She was called back to the HGH cardiac clinic where she had a loonie-sized pacemaker implanted that will keep her heart beating in a steady rhythm. She feels very well now and only needs checkups every six months.

Dr. Natarajan is the principal investigator on REdireCT TAVI, a clinical trial into whether remote ECG monitoring of patients before TAVI and after they go home is the answer to efficiently determining who requires a pacemaker, thereby reducing hospital stays and readmissions. The two-year study began in June and is being managed through the Population Health Research Institute, a joint institute of Hamilton Health Sciences and McMaster University. “This is almost an early warning system so that before patients develop symptoms, we can see episodes of abnormal heart rhythms. Those patients then come directly back to us rather than to their local hospital or the emergency department,” says Dr. Natarajan. Remote monitoring before TAVI surgery can also alert doctors to arrhythmia or other abnormalities that, in serious cases, can be addressed by implanting a pacemaker during the TAVI procedure. “Whenever hospital stays are reduced or prevented, that’s better for patient comfort and recovery, and is a more cost-effective and efficient use of healthcare resources,” says H Dr. Natarajan. ■

Meredith MacLeod is a freelance journalist in Hamilton. www.hospitalnews.com

FEBRUARY 2019 HOSPITAL NEWS 45

SAFE MEDICATION

Medication incidents involving immunosuppressive agents By Melody Truong, Amanda Chen, Jim Kong, and Certina Ho mmunosuppressive agents or immunosuppressants are a class of medications indicated for their immunomodulatory effects on autoimmune disease progression. They are typically cautiously prescribed due to their unique dosing regimens and broad spectrum of potential drug interactions. Their overall complexity and therapeutic role, while important, can cause significant patient harm when used incorrectly due to medication errors. The Institute for Safe Medication (ISMP) has identified immunosuppressant agents (such as Azathioprine, Cyclosporine, Tacrolimus) as high-alert medications in community/ambulatory settings. A list of high-alert medications in community/ambulatory settings is available at https://www.ismp.

I

org/recommendations/high-alert-medications-community-ambulatory-list At ISMP Canada, we conducted a multi-incident analysis on medication incidents involving immunosuppressants in community pharmacy practice. All relevant medications of interest were extracted according to the American Hospital Formulary Service (AHFS) classification system from the American Society of Health-System Pharmacists. The list included Azathioprine, Cyclosporine, Mycophenolate, Sirolimus, and Tacrolimus. Intravenous immunosuppressants were excluded from this analysis as they are not typically prescribed/dispensed in the community/ambulatory setting. All medication incident data were gathered from the ISMP Canada’s Community Pharmacy Incident Re-

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porting (CPhIR) program from a fiveyear period between January 2010 and May 2015. Three main themes and five sub-themes were realized from this qualitative, multi-incident analysis.

dent analysis, we identified the underlying contributing factors to these incidents and recommended system-based solutions to help prevent future errors (Table 1).

MAIN THEME 1: WRONG INDICATION

MAIN THEME 2: EFFECTIVENESS

Given the plethora of drug names on the market, comparable or similar drug products were often prescribed and/or dispensed for the wrong indication. Immunosuppressants are no exception to this, with contributing factors such as look-alike/sound-alike drug names and similar formulation titles perpetuating these errors. An example of a mediation incident involving wrong indication was that of Azathioprine, whose brand name is Imuran®, being mistakenly read as Januvia®, a medication used for diabetes. As well, extended-release Tacrolimus, which is branded under Advagraf®, was commonly mistaken for Prograf®, the immediate-release formulation. Through this multi-inci-

The theme of effectiveness refers to medication incidents that were due to under-dosing of the medication. Immunosuppressants are prescribed under a wide range of therapeutic dosing schedules and it is crucial to confirm the indicated dose with prescribers and/or patients at each stage of the mediation-use process. An example of a medication incident involving under-dosing of Mycophenolate 1000 mg twice daily, i.e. a total daily dose of 2000 mg, being dispensed as Mycophenolate 500 mg with instructions to take two tablets once daily, i.e. under-dosing by 50 per cent of the original intended total daily dose. Table 2 summarizes recommended solutions to prevent these incidents.

Table 1. Recommendations for Prevention of Wrong Indication Related Medication Incidents Sub-themes

Potential Contributing Factors

Recommendation

Look-alike/ Sound-alike (LASA) Drug Names

Handwritten prescriptions Confirmation bias

Utilize electronic prescription order sets Perform independent double checks in the medication-use process Request prescribers to include indication on prescription orders Gather information from patients during counselling and monitoring of drug therapy

Formulation Mix-up

Knowledge gaps Confirmation bias

Implement computerized alerts and reminders for high-alert drugs Relocate or segregate LASA drug pairs in storage areas to prevent association by proximity

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SAFE MEDICATION Table 3. Recommendations for Prevention of Safety Related Medication Incidents

MAIN THEME 3: SAFETY Medication incidents involving safety concerns are critical issues to address with any class of medications, especially immunosuppressants. The potency of immunosuppressants may lead to severe harm in patients when toxicity occurs due to either over-dosing or drug interactions. Toxic effects can range from secondary infections to bone marrow suppression and blood dyscrasias, all of which can be fatal. Clinicans should remain vigilant regarding dosing instructions and confirm that they are safe and appropriate for the patient. Any marginal

errors may easily result in over-dosing and elevated serum levels of the immunosuppressant. Table 3 summarizes recommendations to prevent safety related medication incidents. Medication incidents highlight the vulnerability of our current healthcare system regarding the use of highalert medications such as immunosuppressants and many others. The recommendations provided here is a starting point for healthcare practitioners to share and generate more open discussions regarding medication incidents, with an ultimate goal to provide safe and effective patient H care. ■

Table 2. Recommendations for Prevention of Effectiveness Related Medication Incidents Sub-themes

Potential Contributing Factors

Recommendation

Under-dosing

Confirmation bias Reliance on mental calculations

Perform independent double checks in the medication-use process Implement rules and policies for handling high-alert medications (e.g. documenting calculations on prescriptions during order-entry)

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Sub-themes

Potential Contributing Factors

Recommendation

Toxicity Due to Overdosing

Lack of independent double checks Lack of patientpractitioner communication Knowledge gaps

Perform independent double checks in the medication-use process Engage in counselling and follow-up conversations with the patient to address potential misuse of medications and ensure compliance

Toxicity Due to Drug Interactions

Lack of patient-practitioner communication among multiple healthcare providers in the patient’s circle of care Incomplete continuity of care (e.g. lack of medication reconciliation at the transition points of care)

Encourage regular communication amongst healthcare providers within the patient’s circle of care whenever changes are made to a patient’s drug therapy Encourage patients to pick up medications from the same pharmacy for consolidated and comprehensive medication profiles

Melody Truong is a Clinical Pharmacist at Credit Valley Hospital, Trillium Health Partners, and a Consultant Pharmacist at the Institute for Safe Medication Practices Canada (ISMP Canada); Amanda Chen is a Clinical Pharmacist at Sunnybrook Health Sciences Centre; Jim Kong is a Program Development Manager at ISMP Canada; and Certina Ho is a Project Lead at ISMP Canada.

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