Hospital News 2017 August Edition by Hospital News

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August 2017 Edition

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Spinal cord stimulation treatment improves mobility in patients with

Parkinson’s disease By Jessica Bonin fter being diagnosed with Parkinson’s disease in 2002, Larry Walleyn developed gait freezing. He had a hard time getting around, sometimes he couldn’t move at all and falls were frequent. His symptoms caused him to lose much of his independence. Gait freezing is a symptom of Parkinson’s disease. It hinders the ability to produce continuous stepping movements. Freezing is unpredictable, which increases the risk of falls and injuries. Freezing episodes can be as short as a few seconds or can last hours. A year ago, Larry became the first patient in Canada to undergo spinal cord stimulation (SCS) surgery in a study led by Lawson scientist Dr. Mandar Jog. In this surgery, two leads that send out electrical pulses are placed along the spinal cord in a patient’s lower back. A handheld device can control the frequency and strength of the electrical pulses. After receiving the surgery, Larry says he saw a “huge improvement.” According to Larry’s wife, Brenda Alderson, “As soon as they turned on the device for the first time, his walking improved and he wasn’t freezing as much. It kept getting better as time went on. Now I have a hard time keeping track of where he is sometimes!” As part of this study, four other patients with advanced Parkinson’s disease have received the surgery, performed at London Health Sciences Centre (LHSC)’s University Hospital by Dr. Andrew Parrent, Lawson scientist and Chief of Neurosurgery at LHSC. After the surgeries, Dr. Jog and his team then personalized the settings for the SCS over six months. The participants walked along a gait carpet wearing a motion capture body suit that allows the researchers to analyze all aspects of their gait, from head to toe.

(l-r): Olivia Samotus, PhD candidate; Larry Walleyn, research participant; and Dr. Mandar Jog.

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Using this data, they ensure the SCS is individualized to each patient’s gait dysfunction. The five participants experienced an average decrease in the number of freezing episodes from 16 to zero over six months, and showed significant improvements in walking speed and length of steps. “Gait freezing limits the ability to perform daily activities so the improvements we’ve seen from SCS have really meant a better quality of life for these patients. For example, one patient was wheelchair bound before the study and now only uses it for long distances,” says Dr. Jog, who is also a neurologist at LHSC and a professor at Western University’s Schulich School of Medicine & Dentistry. “Considering gait freezing usually goes untreated, the potential for SCS to help patients with advanced Parkinson’s disease is very exciting.” Oral medications have no impact on gait for many patients. Deep brain stimulation (DBS) surgery often provides minimal to no change in gait and only a fraction of patients are eligible for the surgery. In comparison to DBS surgery, SCS is minimally invasive and less risky, which would allow a wide range of patients to undergo the treatment. The study, led by Dr. Jog is the first to use objective measures of gait and whole-body movements to better tailor SCS to each patient’s symptoms. With the five patients who participated in this study, a total of 33 human case studies on SCS have been published around the world. “More research is needed to understand the full effects of SCS in improving gait dysfunction,” adds Dr. Jog. Dr. Jog and his team plan on treating 20 more patients over the next three years, and will study changes to brain and spinal activity over a one-year peH riod of using SCS. ■

Jessica Bonin is a Communications Associate at Lawson Health Research Institute. www.hospitalnews.com

Contents August 2017 Edition

IN THIS ISSUE:

Moving critically ill children

17 ▲ Cover story: Lifesaving in-utero heart procedure

▲ New cozy cloths aid preemies’ development

16 ▲ Neurological rehabilitation services closer to home

This Issue

Spinal cord stimulation treatment ......... 2 Editor’s note ............................................ 4 In b rief ...................................................... 6 Helping patients take steps toward rehabilitation ..................... 8 Screening tool to assess kids’ mental health................... 14 Collaborative approach to autism research ................................15 Youth and alcohol..................................18 SickKids’ Children’s Council .................20 Congenital heart defect ........................22 Swabbing for respiratory viruses..........22 Product s potlight ...................................23 Safe medication .................................... 24 Evidence matters ..................................25 From the CEOs desk..............................26 Community stroke rehabilitation ..........28 Events ....................................................30 Nursing pulse ........................................30 Careers .................................................. 31

10 ▲ Erasure of negative memories one step closer to reality

Topicall NSAIDs: ere it hurts Right where

▲ A safe solution for skin-to-skin

Obstetricians and gynecologists target reductions in unnecessary care By George D. Carson and Wendy Levinson ere is, perhaps, a surprising fact: Birth is the most common reason that Canadian women are hospitalized each year. There were over 350,000 babies born in hospitals across the country last year. And the most common in-hospital surgery is caesarean section delivery, with approximately 100,000 performed annually. So obstetricians and gynecologists provide a lot of patient care, for both pregnancies and other aspects of women’s health. Here’s another important fact: A recently released report from the Canadian Institute of Health Information found that up to 30 per cent of all healthcare provided offers no value to patients. Knowing this, it’s time to ask if women are being given unnecessary care, not only during pregnancy and labour, but throughout their lifespan. The Society of Obstetricians and Gynecologists of Canada (SOGC) recently joined Choosing Wisely Canada, a clinician-led campaign to reduce unnecessary care, and in consultation with their membership developed an evidence-based list of recommendations: Ten Things Physicians and Patients Should Question. The list includes unnecessary tests and procedures in labour, delivery and gynecological care that offer no value to patients and may potentially cause harm. Unnecessary care is also costly to the Canadian healthcare system. Such guidelines would have helped Tracey and her care providers. Tracey was pregnant with her second child af-

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ter a successful, healthy first pregnancy. Her care provider recommended a Doppler study of the umbilical arteries. But evidence shows that Doppler studies are helpful only for high risk pregnancies. In low risk pregnancies, this intervention most often leads to false positives. This is exactly what happened with Tracey. Abnormal flow in the umbilical arteries was seen on the ultrasound and she subsequently underwent multiple ultrasounds and blood tests to ensure that the growing baby was safe. She lived in a rural location and had to make several trips to the referral hospital for assessments. This caused her a great deal of unneeded anxiety and wasted health care (and the patient’s own) resources that could have been put to better use elsewhere. It turned out that all was normal and Tracey had a healthy baby. The Doppler study was inappropriately applied in this case at a cost to the patient and the healthcare system. This is why the SOGC recommends Doppler studies be reserved for high risk patients only. Another item on the list of 10 cautions for unnecessary routine care include routine episiotomy. Episiotomy is when a cut is made right before a baby is delivered to try to widen the vaginal opening and reduce potential tearing. But evidence now shows this pre-emptive cut can lead to increased pain, longer periods of healing and potential complications down the road. Sometimes, in an emergency, an episiotomy is needed but it should not be done routinely. Continued on page 7

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Monthly Focus: Monthly Focus: Emergency Services/Critical Care/Trauma/EmerPatient Safety/ Mental Health and Addiction/ gency Preparedness/Infection Control: Innovations Research: Developments in patient-safety practices. in emergency and trauma delivery systems. EmerAdvances in the measurements of patient outcomes gency preparedness issues facing hospitals and how and program metrics. New treatment approaches to they are addressing them. Advances in critical care mental health and addiction. An overview of current medicine. Programs implemented to reduce hospital research initiatives. acquired infections. Developments in the prevention + Health Achieve Annual Conference Guide and treatment of drug-resistant bacteria and control Supplement of infectious diseases. + Online Education Supplement THANKS TO OUR ADVERTISERS Hospital News is provided at no cost in hospitals. When you visit our advertisers, please mention you saw their ads in Hospital News. 4 HOSPITAL NEWS AUGUST 2017

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

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IN BRIEF

The Lancet Commission:

One third of dementia may be preventable n a report presented at the Alzheimer’s Association International Conference 2017 (AAIC 2017) in London, The Lancet International Commission on Dementia Prevention, Intervention and Care reported that more than one third of global dementia cases may be preventable through addressing lifestyle factors that impact an individual’s risk. These potentially modifiable risk factors have been identified at multiple phases across the life-span, not just in old age. The Lancet Commission’s report was simultaneously published in The Lancet and presented at AAIC 2017. The Lancet Commission brings together 24 international experts to consolidate the huge strides that have been made in our knowledge and understanding of dementia risk factors, treatment and care, and the emerging knowledge as to what we should do to prevent and manage dementia. The

6 HOSPITAL NEWS AUGUST 2017

MANY OF THE RISK FACTORS OCCUR AT PARTICULAR LIFE STAGES BUT SOME, SUCH AS SMOKING AND HYPERTENSION, ARE LIKELY TO MAKE A DIFFERENCE AT ALL LIFE STAGES. Commission conducted a new review and meta-analysis; based on which they extended current models of risk by including hearing loss and social isolation. Incorporating potentially modifiable risk factors from across the life-span, they proposed a novel lifecourse model of risk, highlighting the opportunity for prevention. Among their key recommendations are: • Be ambitious about prevention. Interventions for established risk factors may have the potential to delay or prevent one third of dementias. • Treat cognitive symptoms. To maximize cognition, people with Alzhei-

mer’s dementia or dementia with Lewy bodies should be offered cholinesterase inhibitors at all stages, or memantine for severe dementia. • Individualize dementia care. Good dementia care spans medical, social and supportive care; and should be tailored to unique individual and cultural needs, preferences, and priorities. • Care for family carers. Family carers are at high risk of depression. Effective interventions reduce the risk and treat the symptoms, and should be made available. • Plan for the future. People with dementia and their families value

discussions about the future and important upcoming decisions. • Manage neuropsychiatric symptoms. Management of the neuropsychiatric symptoms of dementia - including agitation, low mood or psychosis - is usually psychological, social, and environmental, with drug treatment reserved for more severe symptoms. • Consider end of life. A third of older people die with dementia, so it is essential that professionals working in end-of-life care consider whether a patient has dementia as they may be unable to make decisions about their care or express their needs and wishes. The Lancet Commission launched a novel life-span-based model of dementia risk, showing interventions that may maximize cognition, decrease distressing associated symptoms, reduce crises, and improve quality of life. Continued on page 7

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IN BRIEF

Obstetricians and gynecologists Continued from page 4 Another of the 10 cautions includes continuous electronic fetal monitoring. Fetal heart rate monitoring has been done in the past to ensure that babies are not in distress during labour. But evidence now shows that sometimes during labour and delivery there are changes in the heart rate that can be misinterpreted by even the most seasoned clinician as a baby in distress. Research has shown that increased monitoring doesn’t reduce birth complications, but does increase potentially unnecessary interventions in labour and increases the rate of C-sections. Obstetricians do need to follow the well-being of the fetus in labour, but most deliveries are low-risk so listening to the heart rate intermittently is effective. For gynecological health throughout life, there have been tremendous advances in screening for diseases such as cancer, but certain screening tests can do more harm than good. This is why the list includes not doing pap smears to detect cervical cancer for women under the age of 21 and over age 70. Routine cervical cancer screening for women in these age groups hasn’t been shown to provide any benefit and high false positive rates lead to more investigations and potential harms. Screening for ovarian cancer in lowrisk women has also been shown to cause more harm than good. Studies show such screening results in a high number of false positives, causing overtreatment and complications – with no lives saved. In medicine, as in life, more is not always better. The best medicine is based on evidence, and Choosing Wisely lists are a good reminder of how we can continue to improve the quality of care we H provide to Canadian women. ■ George D. Carson is a Clinical Professor of Obstetrics, Gynecology and Reproductive Sciences at the University of Saskatchewan. He is the President of the Society of Obstetricians and Gynecologists of Canada. Wendy Levinson is an expert advisor with EvidenceNetwork.ca and a Professor of Medicine at the University of Toronto. She is the Chair of Choosing Wisely Canada. www.hospitalnews.com

New survey on Canadians and health literacy ccording to a new survey by Consumer Health Products Canada (CHP Canada), Canadians with higher health literacy scores tend to enjoy better health. Overall, the health literacy of Canadians compares well with Europeans in terms of health knowledge and disease prevention, though Canadians struggle more with navigating the healthcare system, while finding it a little easier to judge their different treatment options. The survey was based on an approach developed by the European Health Literacy Project and looked at knowledge of healthcare, disease prevention and health promotion, while also exploring information processing and health related decision making. Respondents were then grouped together into four seg-

ments, characterizing their health literacy as either excellent, sufficient, problematic or inadequate. Overall, 73% of Canadians fell into the “excellent” or “sufficient” categories, compared to 61% of Dutch, 60% of Irish, 56% of Poles and 54% of Germans. However, the survey also shows that, like Europeans, Canadians can find it challenging to judge the reliability of health information other than the information they get from their doctor or pharmacist. Canadians also struggle in other areas: • 23% of Canadians find it “fairly difficult” or “very difficult” to find out where to get professional help when they are ill, compared to only 5% of Dutch, 9% of Irish, 13% of Germans and 14% of Poles; • 54% of Canadians found it “fairly diffi-

cult” or “very difficult” to judge when to seek a second opinion from another doctor, compared to 46% of Dutch, 45% of Germans, 38% of Irish and just 25% of Poles. Other Statistics on Canadians and health literacy: • 89% of Canadians use their doctor for health advice vs 67% for pharmacists; • 53% of Canadians find it difficult to judge the reliability of information on health risk in the media; • 36% of Canadians find it difficult to find information on how to manage health problems like stress and depression; • 35% of Canadians find it difficult to judge different treatment options; • 34% of Canadians find it difficult to judge which health screenings they H should have. ■

Lancet Commission Continued from page 6 The team estimate the contribution of each of the risk factors to the overall incidence of dementia, at the population level. The combined evidence to date shows that roughly 35 per cent of all cases of dementia are attributable to nine potentially modifiable risk factors. Many of the risk factors occur at particular life stages but some, such as smoking and hypertension, are likely to make a difference at all life stages. The nine modifiable risk factors include: • Early life – Education to a maximum of age 15 • Mid-life – Hypertension; Obesity; Hearing loss • Later life – Depression; Diabetes; Physical inactivity; Smoking; Low social contact Risk factors that are more common account for a higher percentage of population risk. For instance, the authors estimate that eight percent (8%) of all dementia cases could be associated with poor early school education; and five percent (5%) could be associated with smoking. While the mechanism linking education, hypertension, diabetes and smoking to dementia is relatively well understood, the recognition of hearing loss as a potential risk factor is still new,

and the research is at an earlier stage. The Commission’s report delivered recommendations for targeted public health strategies that the researchers expect will significantly lower the global burden of Alzheimer’s and other dementias. For example: • The authors strongly recommend vigorously treating hypertension in

middle aged and older people without dementia to reduce dementia incidence. • Other recommended interventions include more childhood education, getting regular exercise, maintaining social engagement, stopping smoking, and management of hearing loss, deH pression, diabetes, and obesity. ■

AUGUST 2017 HOSPITAL NEWS 7

Helping acute care patients take steps toward rehabilitation

FOCUS

By Michael Oreskovich unnymede Healthcare Centre’s low tolerance long duration rehabilitation program (LTLD Rehab) focuses on restoring independence for patients who have reduced mobility after an injury or surgery and helps bridge the gap between acute care and home. At the start of their recovery journey, patients often feel uncertain about how they will be able to resume their lives upon returning to the community. Runnymede’s patient flow department provides support to patients like these by ensuring their concerns are addressed before they enter LTLD Rehab, and that their admission to the hospital from acute care is seamless. Runnymede’s close integration with its healthcare partners makes patient flow’s role in the hospital essential. The department collaborates closely with referring acute care centres to admit patients who need Runnymede’s specialized level of care and meet the LTLD Rehab program’s criteria. They coordinate the flow of information about new patients between referring organizations and the hospital’s interprofessional team. The department also works to enhance the patient experience before admission by providing support to patients and their families. “When patients are being transferred from acute care to a rehabilitation hospital like ours, it can be overwhelming,” says Runnymede’s Vice President of Strategy, Quality and Clinical Programs, Sharleen Ahmed. “Our hospital’s patient flow team uses an innovative approach for guiding families through this process by assigning one contact person – our admissions coordinator – to each patient before their admission to answer questions and address their concerns.” Unique to Runnymede, the admissions coordinator role strengthens the hospital’s delivery of client-centred care. When reaching out to patients or family members, the coordinator lays out a vision for what rehabilitation at

Runnymede Healthcare Centre’s patient flow manager, Lisa Dreher (right) collaborates with interprofessional team members to facilitate admissions. As the hospital’s first point of contact for new patients, patient flow team members also provide important client-focused support before admission. Runnymede helps acute care patients take steps toward rehabilitation Runnymede will look like – how long it is expected to take, and the clinical outcomes they can anticipate. They also frequently raise awareness about existing community resources that are in place to ensure the patient continues to thrive after discharge from Runnymede back into the community. These pre-admission conversations with patients and families give the patient flow team an opportunity to learn about what the patient wants to get out of their rehabilitation at Runnymede. They communicate these treatment goals to the clinical team along with a summary of the patient’s medical history and any special needs they have. From that initial touchpoint with patient flow, the clinical team can prepare for the patient’s arrival. The single point of contact that patients and families have through patient flow’s admissions coordinator doesn’t just simplify communications, it also builds trust. This is particularly important if patients are anxious about transferring to a rehabilitation hospital like Runnymede because they feel their

immediate needs are being met in an acute care setting. A recent example of this involved a patient who suffered a fall at home. After two months in an acute care hospital, his injuries improved but he was unable to move independently and couldn’t safely return to his house. “Staff at the acute care hospital informed the patient and his family that admission to LTLD Rehab was what he needed to recover and return to the community,” says Lisa Dreher, Runnymede’s patient flow manager. A bed was available within days, but the patient’s family refused the offer. “Because of his limited abilities, his family didn’t feel he was prepared to resume his life at home.” After patient flow discussed the rehabilitation process and helped the patient’s family understand the supports that would be available after discharge, they were inspired with confidence to proceed with rehabilitation. “He was admitted to Runnymede in 2016 and after two months in LTLD Rehab, the patient’s strength and independence

progressed rapidly and he was able to return home,” says Dreher. Since his discharge, the patient’s family has successfully worked with community agencies to ensure that supports are in place to help the patient live at home independently and safely. One of patient flow’s goals is to help patients navigate the healthcare system - which can at times seem complicated – to ensure they get the right care, in the right place, at the right time. But according to Ahmed, the department is also vital for putting patients at the centre of their own decision making, by addressing their needs before admission. “We never lose sight of the fact that every patient that comes through our doors is someone who has questions about their health and wants to get better,” she says. “Our patient flow team is an example of how we always do our best to find new ways of addressing patients’ concerns and empower them to continue their recovery journey even after they’ve completed their rehab at our hospital and have been discharged H to the community.” ■

Michael Oreskovich is a Communications Specialist at Runnymede Healthcare Centre. 8 HOSPITAL NEWS AUGUST 2017

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Neurological rehabilitation

Providing services closer to home By Danae Theakston or many patients who suffer a neurological injury, the journey to recovery continues long after discharge from the hospital. Outpatient neurological rehabilitation services allow patients to continue to work towards their recovery and improve their quality of life. Not only does this enable patients to return home and begin re-engaging in life, but it also reduces the number of bed days patients are spending in hospital, thus streamlining internal bed flow.

A patient of the Neurological Rehabilitation Outpatient Clinic receives physiotherapy for their neurological condition from Southlake Physiotherapist Leya Bennett.

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The clinic is helping patients with acute neurological events such as recent strokes, tumor resection, head traumas, and more. The outpatient neurological rehabilitation clinic is focused on providing rehabilitation services to patients closer to home despite the location of their initial medical/surgical and rehabilitation treatments. Incidentally, the clinic has also been able to offer therapy to patients who have not had any acute or rehabilitation inpatient admission.

“THE EMOTIONAL AND HOLISTIC IMPACT OF BEING ABLE TO HAVE ACCESS TO THESE SERVICES WHILE LIVING AT HOME AIDS IN OUR PATIENTS’ ABILITIES TO SUCCESSFULLY RESUME A NORMAL LIFE.” Noticing a void in the Central LHIN to offer these services, Dr. David Srour, Physician in the Complex Medical Rehab and Medicine Programs at Southlake Regional Health Centre, together with the neurological rehabilitation team, lead a proposal for funding to open an Outpatient Neurological Rehabilitation Clinic to offer these services. In December 2016, Southlake Regional Health Centre received temporary funding through the Central LHIN to begin offering outpatient services to patients with recent neurological injuries within the boundaries of the Central LHIN. “Our successes to date have been numerous,” notes Sarah Thorne, an Occupational Therapist and Coordinator in the clinic. “We have more than doubled our target volume of referred/ admitted patients for the first quarter, despite a soft opening and initially shallow referral pool.”

The clinic team offers Physiotherapy, Occupational Therapy and Speech-Language Pathology services three full days per week. In addition, clerical and rehabilitation assistance/ communicative disorders assistance support is available to patients on a part-time basis, five days per week. “Our clinicians have had the opportunity to offer functional, patient-specific and goal-directed therapies from which we have received overwhelming feedback,” adds Thorne. “The emotional and holistic impact of being able to have access to these services while living at home aids in our patients’ abilities to successfully resume a normal life.” The Outpatient Neurological Rehabilitation Clinic will continue to help patients re-engage with their lives by helping facilitate the return to work, school, leisure, travel and functional H independence until March 2018. ■

Danae Theakston works in Communications at Southlake Regional Health Centre. www.hospitalnews.com

Jim walks the walk.

Jim Vigmond’s handshake is as firm as his commitment to helping his personal injury clients receive fair verdicts. This founding partner is also committed to his philanthropic pursuits. Among his many charitable organizations, Jim raises funds and travels to Cambodia every year to assist underprivileged women house themselves while giving them the opportunity to go to law school. Lending a hand comes naturally. With exceptional experience in spinal cord and brain injury law, Jim knows that his legal contributions will make a profound difference in the outcome of his client’s life. For Jim, their right to fair compensation isn’t just of vital importance; it’s his professional mission. Jim doesn’t have to be in court to talk the talk. Jim would be quick to tell you that despite all his success, nothing compares to the joy of actually being able to make a difference in someone’s life.

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PAEDIATRICS

Race against the clock:

Lifesaving in-utero heart procedure By Matet Nebres and Sally Szuster t’s not very often that a baby’s first foray into the world would also mark his second time in an operating room. Five days before he was born, a surgical procedure was performed on Baby Sebastian Havill’s heart while he was still in his mother’s womb. Sebastian was diagnosed prenatally with a severe form of a congenital heart defect called Transposition of the Great Arteries (TGA), which affects about five to seven per cent of babies with congenital heart defects. Complicating his heart disease was the fact that all the walls in his heart – the atrial and ventricular septa – were closed shut, which would have prevented his blood from receiving oxygen after birth.

12 HOSPITAL NEWS AUGUST 2017

On May 18, doctors from The Hospital for Sick Children (SickKids) and Mount Sinai Hospital, part of Sinai Health System, inserted a balloon into Sebastian’s heart, via a needle placed under ultrasound guidance through his mother’s uterus, to open up the atrial septum. It is believed that this is the first time in the world that this procedure – a Balloon Atrial Septoplasty (BAS) – has been performed before birth to treat Sebastian’s particular condition. The BAS procedure did not address his heart condition – Sebastian still needed open-heart surgery after birth. However, by creating a 3.5 mm hole in the atrial septum in utero, Sebastian and his mom, Kristine Barry, were

FIVE DAYS BEFORE HE WAS BORN, A SURGICAL PROCEDURE WAS PERFORMED ON BABY SEBASTIAN HAVILL’S HEART WHILE HE WAS STILL IN HIS MOTHER’S WOMB spared a traumatic and potentially life-threatening course after delivery, which may have prevented him from being eligible for the surgery at all. On the day of the procedure, two operating rooms were prepared at SickKids. One team focused on performing the fetal cardiac procedure and another team of neonatal and cardiac surgery specialists were on standby in the next room, should an emergency

delivery and cardiac surgical procedure be required. In total, there were more than 30 clinicians, including surgeons, anaesthesiologists, neonatologists, fetal medicine specialists, interventionists, heart and lung bypass specialists and nurses. The procedure went smoothly, as planned, and an emergency delivery was not needed. “Had it not been for this procedure, the delivery would have had to be by www.hospitalnews.com

PAEDIATRICS Caesarian section, with full neonatal resuscitation and cardiac surgery teams at the ready to perform a critical, lifesaving surgical procedure on Sebastian’s heart. Once out of the womb, he would have become immediately distressed and we would have had only three minutes to open up his heart. Any longer and he would have been at risk of brain damage, stroke or potentially even death,” says Dr. Rajiv Chaturvedi, Staff Interventional Cardiologist at SickKids and a member of the three-physician team that performed Sebastian’s procedure. Sebastian remained safely in his mom’s womb until labour was induced at Mount Sinai Hospital five days later. On May 23, Kristine went on to have a vaginal delivery. “This procedure was extremely high risk, as it had never been done before birth on a baby with this particular condition. This was the bridge we needed to allow Sebastian to have open-heart surgical correction of his TGA,” says Dr. Greg Ryan, Head of the Fetal Med-

icine program at Mount Sinai Hospital, another member of the team that performed the procedure. “Sebastian was born vigorous, pink and screaming. He remained well-oxygenated thanks to the atrial hole that had been created in-utero.” Sebastian was transferred to SickKids and underwent an arterial switch repair to completely correct his condition five days later. The surgery was successful and there were no complications. “Our ability to perform BAS in utero is a paradigm shift in how we may treat this condition in the future,” says Dr. Edgar Jaeggi, Head of the Fetal Cardiac Program at SickKids, the other key member of the team. “With this innovative procedure, we are able to give these babies a significantly better start to life.” The team from SickKids and Mount Sinai Hospital is Canada’s only provider of fetal cardiac procedures and one of only a few worldwide. The group has jointly performed 41 fetal heart surgeries on 32 patients since 2009. “This

Sebastian and his family reunite with the doctors who performed the lifesaving procedure. partnership between our two leading Ontario health centres continues to have a transformative impact on babies’ lives,” says Ryan. Sebastian’s parents, Kristine Barry and Christopher Havill, are now enjoying the early days of parenthood at

home with their son. “In the first moments after we received the diagnosis, it felt like our world crashed around us,” says Kristine. “This team immediately filled us with confidence and we never doubted that we would one day H hold our beautiful and healthy son.” ■

Matet Nebres is Senior Manager of Media Relations at The Hospital for Sick Children and Sally Szuster is Senior Manager of Communications and Public Affairs at Sinai Health System.

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AUGUST 2017 HOSPITAL NEWS 13

PAEDIATRICS

Screening tool makes it easy for emergency physicians to

assess kids’ mental health By Mike Foster simple questionnaire can help busy emergency physicians accurately assess kids’ mental health needs within minutes, a new study shows. The HEADS-ED screening tool developed at the Children’s Hospital of Eastern Ontario (CHEO) allows Emergency Room physicians to rapidly assess whether children and youth need immediate intervention or follow-up referrals. Their decisions were found to be as accurate as assessments made by specialized crisis intervention workers, according to a study, “The HEADS-ED: Evaluating the clinical utility of a brief, action-oriented, paediatric mental health screening tool”, published in the May 2017 edition of Pediatric Emergency Care. Dr. Mario Cappelli, CHEO’s Director of Psychiatric and Mental Health Research, lead author of the study, says: “We’ve shown that emergency physicians can effectively use this tool: it’s as easy and straightforward as a thermometer. More importantly, there’s no difference between how an emergency physician clinically defines levels of need for mental health services compared to a mental health professional.” The HEADS-ED evidence-based interview tool provides standardized questions and a scale for measuring answers. Results can be easily shared with other health professionals. For the study, emergency physicians used the screening tool to accurately guide clinical decisions for more than 600 children aged 12 to 18 who presented with symptoms such as anxiety, self-harm, hallucinations, thoughts of suicide, social problems and substance misuse at CHEO’s emergency department between May 2013 and March 2014. The study is the latest research to emerge from a CHEO-led initiative to improve mental healthcare for children. In 2009, Dr. Cappelli and his research team, supported by a $500,000

Photo: Lucia Figueredo/CHEO Media House

L-R: Paula Cloutier, Mario Cappelli, Chantale Melo in the Children’s Hospital of Eastern Ontario (CHEO) Emergency Department.

SINCE 2012, THE HEADS-ED HAS BEEN OPEN SOURCE, AVAILABLE FREE OF CHARGE IN AN ONLINE OR PAPER FORMAT FROM HEADSED. COM, WHICH INCLUDES TRAINING VIDEOS. matching fund from the RBC Foundation and the CHEO Foundation, began to look at better ways to improve mental health services for children in the emergency department. Working with Dr. Roger Zemek, who was Emergency Department physician lead on the HEADS-ED, as well as CHEO team of psychologists, psychiatrists, emergency department physicians, crisis intervention workers, and research associates, Dr. Cappelli created the streamlined tool by adapting core elements of the HEADS, a com-

mon memory aid used to obtain the psychosocial history of adolescents. The HEADS-ED adaptation was also based on the Child and Adolescent Needs and Strengths Mental Health 3.0 (CANS-MH 3.0), a 60-item inventory that assists decision-making but typically takes an hour to complete. The HEADS-ED tool (the acronym stands for Home, Education, Activities and peers, Drugs and alcohol, Suicidality, emotions and behaviours and Discharge resources) adds key questions for ED physicians to ask paediatric

patients and recommends three levels of action based on responses: a zero for children who require no further action and can return home; a one for those that require follow-up services in future, and a two for immediate action. Dr. Cappelli says accurate screening means better access to mental health services for children. Paediatric emergency departments across Canada and the US have seen a rise in mental health presentations among children and youth. At CHEO, a tertiary care children’s hospital serving a population of around 1.3 million people, around 3,100 children and youth presented to the ED last year with mental health problems. “Emergency services are a gateway. Every year, around five per cent of presentations at our emergency department are children with mental health issues. Emergency physicians fix bones but they don’t necessarily have the formal training to deal with certain mental health problems,” Dr. Cappelli says. Two years ago, the IWK Health Centre in Halifax, Nova Scotia incorporated the HEADS-ED into its procedures for triaging incoming calls from families, children and adolescents with mental health concerns at its Central Referral service. Sharon Clark, advanced practice leader and a registered psychologist at the IWK Health Centre, says last year the HEADS-ED was used 1,749 times and clinicians have been happy with its impact. “The HEADS-ED helped us establish a common method of gathering information, documenting that information and then making decisions about the intensity of mental health care required,” says Dr. Clark. “Previously we didn’t have common domains for the intake workers to use as they gathered information. We have been able to simplify our entire process and be far more H responsive.” ■

Mike Foster is a Communications Specialist / Writer for the CHEO Research Institute. 14 HOSPITAL NEWS AUGUST 2017

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PAEDIATRICS

A collaborative approach to

autism research By Ellie Stutsman taff and researchers at McMaster Children’s Hospital (MCH), McMaster University and Hamilton Health Sciences have come together to form the McMaster Autism Research Team (MacART) to explore how to improve the delivery of care and services for kids with autism and their families. Following the launch of the new Ontario Autism Program, MacART has begun the Pediatric Autism Research Collaborative (PARC) Project. The aim of the Ontario Autism Program is to ensure child and youth ASD services are delivered consistently across the province, while the PARC Project is working to develop a research protocol that can be embedded into the delivery of these services. This will help researchers gain a better understanding of what contributes to

HHS is working to develop a research protocol to better understand what impacts positive outcomes for children with autism to allow for improved care.

healthier outcomes for children with autism. In turn, this will lead to improved individualized, family-centred treatment and care within the available services. “Our researchers are global leaders in the study of autism heterogeneity,” says Stelios Georgiades, founder and co-director of MacART. “The PARC Project will make use of novel methods, developed by our team, to examine the variable trajectories of children and families receiving services in the new Ontario Autism Program.” The PARC Project will allow the ongoing collection of data from children who receive a new ASD diagnosis. It’s been designed for minimal burden on families as the data used is data that’s already collected during a child’s visits to the ASD service program at MCH. There are additional optional stages to

the project whereby families allow additional data to be collected. “We’re excited to have researchers and clinicians working together in a collaborative way,” says Dr. Caroline Roncadin, clinical director of ASD services at the MCH Ron Joyce Children’s Health Centre. “The PARC Project will have the potential to produce research findings that can directly inform the clinical care we provide families.” This unique approach of moving autism research into the clinic encourages collaboration among the families, researchers and clinicians whose lives are touched by ASD. The eventual goal of the PARC Project is to enroll every child and family within the ASD service program into the research protocol. These efforts contribute to MacART’s vision to advance autism care through H meaningful research. ■

Ellie Stutsman is a Public Relations Specialist at Hamilton Health Sciences.

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PAEDIATRICS

Volunteer Jannie Henkelman, the co-ordinator of the Cozy Cloth Program, tends to Benson Mark, a premature infant in the Neonatal Intensive Care Unit.

Photo: Katie Cooper, Medical Media Centre

New cozy cloths aid preemies’ development By James Wysotski arents of premature babies in St. Michael’s Neonatal Intensive Care Unit cannot be at their child’s side 24-7, but now a piece of them can. With the recent launch of the NICU Cozy Cloth Program, parents can leave a triangular piece of fabric with their scent under their infant’s head in the isolette or bassinette. “Parents worry about bonding with their baby when they leave at the end of the day, so it’s a huge source of comfort that their baby can still smell them,” says Amanda Hignell, the social worker from the NICU who developed the program. Parents receive two cozy cloths and are encouraged to wear them under their clothes for 20 minutes so that their scent can permeate the fabric. While the cloths are sized and shaped to fit easily into bras, Hignell says both parents can take part. However, all research to date has focused on the mother-baby relationship.

WITH THE RECENT LAUNCH OF THE NICU COZY CLOTH PROGRAM, PARENTS CAN LEAVE A TRIANGULAR PIECE OF FABRIC WITH THEIR SCENT UNDER THEIR INFANT’S HEAD IN THE ISOLETTE OR BASSINETTE Introducing odours of the mother’s breast milk or amniotic fluid is soothing to babies and helps improve their neurodevelopment, notes Hignell. Another benefit is reduced crying, as well as eliciting a suckling reflex, which is important because that skill is challenging to preemies younger than 35 weeks – and NICU babies tend to be much younger. Teaching babies to suck helps get them feeding sooner by mouth instead of nasal-gastric tubes. While no studies explain the benefits of fathers leaving their scents, Hignell hopes to facilitate paternal bonding as well. “A lot of dads do skin-to-skin kangaroo care while in the hospital, and we know the babies thrive with that,

so I can’t imagine why cozy cloths with their scents wouldn’t work the same way,” says Hignell. While cozy cloths are new for St. Michael’s, the idea isn’t. A few babies transferred from other hospitals’ NICUs arrived with cozy cloths. Sensing the added comfort for both parents and infants, staff there wanted to start a similar program. Hignell enlisted the help of volunteer Jannie Henkelman, a NICU baby-cuddler, to run the new program. Together, they got Fabricland to donate all of the materials. Henkelman co-ordinates the distribution of patterns and materials to volunteer sewers, as well as the pickup of finished products.

A crew of five assembles cloths by diagonally folding 10 by 10 inch squares of cotton flannel, pre-cut by Henkelman, and sewing all of the open edges except for a small hole through which the cloths will be turned inside out. But first, to keep infants safe, excess material at the corners is trimmed, thereby assuring flat, rounded corners after inversion. Then the opening is stitched shut. Each cloth takes about eight minutes to sew. For infection control, the cloths are laundered upon pickup before being placed into plastic bags that get added to the NICU’s Family Welcome Packages. The crew has already made 250 cozy cloths. But with 30 admissions per month to the NICU, the need for more is great. Volunteering for this task is rewarding, says Henkelman. “How satisfying it is to be able to do something as simple as this to enhance the bonding process between preemies and their parents.” To help make cozy cloths, email Jannie Henkelman at cozycloth.smh@ H gmail.com. ■

James Wysotski works in communications at St. Michael’s Hospital. 16 HOSPITAL NEWS AUGUST 2017

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PAEDIATRICS

Paediatric Critical Care Transport Team moving critically ill children By Jonathan Lee magine for a moment you are the parent of a Northern Ontario child with a complex medical history. Put yourself in the shoes of the emergency nurse at a cottage hospital caring for a child who has just been in an accident. Perhaps you relate better to the paediatrician managing a child who has spent several days on the paediatric ward of your hospital. All three of these individuals share two things in common. All three know that much of the province’s specialized paediatric care is centralized and are concerned about how the child for whom they are responsible will make it safely to that specialized care. Ornge, Ontario’s provider of air ambulance and critical care transport, has a solution to the challenges of moving critically ill children: a Paediatric Critical Care Transport Team. Ornge’s Paediatric Team has a combination of capabilities, composition and reach that makes them unique within the province.

viding high quality care to high acuity patients, but in order to add specific paediatric expertise, Ornge adopted an interdisciplinary model for paediatric transport. In 2010, Ornge recruited Registered Nurses with a wide range of backgrounds that includes both paediatric and neonatal intensive care, as well as neonatal transport and anaesthesia assistant. Once hired, the nurses began the exhaustive process of cross training as Primary Care Paramedics. This allowed the nurses to function as part of an ambulance crew in Ontario. Pairing specialized nurses with experienced Critical Care Paramedics provided a novel team composition that brings hospital expertise to the “out of hospital” environment. A number of highly skilled hospital-based teams are available to service paediatric transport in Ontario, but Ornge occupies a unique position within this group. Ornge provides the only paediatric team that operates as part of an ambulance service. This

Since 2011, the team has transported over 2,000 patients. From the Golden Horseshoe to the James Bay Coast, from car accidents to cancer care; Ornge’s approach to paediatrics is as unique as the population they

serve. Whether you are a rural parent, an ER nurse, or a paediatrician, the Ornge Paediatric Critical Care Transport Team is available to provide the highest quality, family and patient centered H care possible. ■

IN 2010, ORNGE RECRUITED REGISTERED NURSES WITH A WIDE RANGE OF BACKGROUNDS THAT INCLUDES BOTH PAEDIATRIC AND NEONATAL INTENSIVE CARE, AS WELL AS NEONATAL TRANSPORT AND ANAESTHESIA ASSISTANT Recognizing the benefits that children receive from specialized care, Ornge has worked hard over the last number of years to improve their paediatric capabilities. One of the first steps was the addition of a group of paediatricians that had a background in either paediatric emergency medicine or critical care, as well as an interest in transport. One of them is available around the clock through Ornge’s Operations Control Centre to provide medical oversight to every child under Ornge’s care. Paramedics within the air ambulance system in Ontario have a history of pro-

means the team is able to respond immediately to any request for service that occurs within the Greater Toronto Area. Additionally, being based close to Pearson Airport allows the team to be easily dispatched on helicopter or fixed-wing aircraft for paediatric patients across Ontario, whichever option is most suitable for the patient. The ability to operate seamlessly and self-sufficiently gives the Ornge paediatric team an unmatched response time as well as the ability to service any healthcare facility in the province of Ontario.

Jonathan Lee is a Paediatric Critical Care Paramedic with ORNGE. www.hospitalnews.com

AUGUST 2017 HOSPITAL NEWS 17

PAEDIATRICS

Almost 2,200 youth were hospitalized for conditions caused by alcohol last year By Alison Clement new report from the Canadian Institute for Health Information (CIHI) provides a closer look at hospitalizations for alcohol harm and identifies youth (ages 10-19) as one of the populations at risk. According to Alcohol Harm in Canada: Examining Hospitalizations Entirely Caused by Alcohol and Strategies to Reduce Alcohol Harm, 77,000 people were hospitalized for conditions entirely caused by alcohol last year. That number is greater than the number of people who were hospitalized following a heart attack. Of them, almost 2,200 were between the ages of 10 and 19. The report highlights that these numbers are only the tip of the iceberg because they don’t include people who went to an emergency department for alcohol-related conditions but were not admitted as inpatients. It also does

not include people who experienced any kind of injury related to alcohol use (e.g. in a road crash) or serious illnesses like cancer where alcohol only causes a proportion of cases. The report focuses on hospital stays for the treatment of conditions considered to be wholly (100%) caused by the harmful consumption of alcohol. Some of the top physical conditions entirely caused by alcohol in 20152016 were alcohol induced cirrhosis of the liver (13%), alcohol induced acute pancreatitis (6%) and alcohol induced hepatitis (4%).

Girls had higher rates of hospitalization than boys The report showed that males age 20 and older had higher rates of heavy drinking and hospitalizations than females in the same age group. How-

ever, among those age 10 to 19, girls had higher hospitalization rates than boys, with 63 per 100,000 and 45 per 100,000, respectively. This is the only period throughout the lifespan where hospitalizations entirely caused by alcohol among females outnumber those among males. The most common diagnoses for hospitalizations for this age group were harmful alcohol use and alcohol intoxication.

The majority of hospitalizations were linked to mental health and addictions Almost three out of four alcohol-related hospitalizations were linked to conditions related to mental health and addictions. Examples include chronic alcohol use disorder, alcohol withdrawal and alcohol intoxication. “Numerous factors can be contributing to the high rates of association between alcohol-related disorders and other psychiatric disorders. In my practice as a child and adolescent psychiatrist, I often come across youth who are self-medicating with alcohol to cope with symptoms related to their mental health illness,” says Dr. Sinthuja Suntharalingam, a psychiatrist at the Children’s Hospital of Eastern Ontario – Ottawa Children’s Treatment Centre. “Patients, including youth, with alcohol-use disorder are more likely to experience concurrent psychiatric illnesses. It is also common for them to experience alcohol-induced mental health disorders. Even the signs and symptoms of alcohol intoxication and alcohol withdrawal can mimic psychiatric disorders, such as depression, anxiety and psychosis.”

The burden of alcohol-related hospitalizations on the system and the patients In 2014–2015, the average cost per hospitalization entirely caused by alcohol was estimated to be $8,100

– higher than the cost of the average hospital stay ($5,800). The higher cost of hospitalizations entirely caused by alcohol is mainly due to longer lengths of stay: an average of 11 days in hospital, compared with 7 days for all hospitalizations.

Prevention strategies and recommendations Evidence shows that screening and brief interventions are an effective way to reduce harmful drinking and alcohol-related harm in primary care and emergency care settings. The Commonwealth Fund’s 2016 International Health Policy Survey found that among Canadians age 18 and older, 25 per cent of males and 22 per cent of females reported having talked about alcohol use with a healthcare provider in the past two years. For both males and females, Alberta had the highest reported rates of talking about alcohol use with a care provider. The troubling alcohol hospitalization numbers behind youth warrant attention in harm reduction and prevention strategies as this age group is at increased risk of negative experiences from alcohol compared with adults. Prevention efforts focused on young Canadians have the potential to reduce both short term and long term risks of alcohol harm. “Evidence shows that strong alcohol policies can be effective in reducing such harms. Effective policies include maintaining high minimum alcohol prices, pricing by alcohol strength, restricting the hours of sale and limiting numbers of liquor outlets,” says Tim Stockwell, University of Victoria’s Centre for Addictions Research of BC. “It is striking to see that alcohol sends so many Canadians to hospital, and these numbers are really just the tip of the iceberg.” For more results and information on alcohol hospitalizations in Canada, CIHI also produces a regional level indicator on alcohol available through its H Your Health System web site. ■

Alison Clement is a Communications Specialist at The Canadian Institute for Health Information (CIHI). 18 HOSPITAL NEWS AUGUST 2017

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PAEDIATRICS

The Joeyband can be used to secure the infant to mother’s breast and if positioned at the right angle the infant will nuzzle over and initiate feeding while the doctors are finishing on the other side of the drape.

A safe solution for skin-to-skin By Hayley Mullins n 2012, I was practicing skin-to-skin (STS) with my two week old daughter, when I took my hands off her for a brief moment – in that split second she fell to the floor. Devastated and determined not to let it happen again, I tried the wraps, carriers, slings and baby wearing shirts that existed in the market at the time – nothing did what I wanted them to do, which was to literally belt my sleeping baby to me. Partnering with my sister, Ashley Wade, we brought a new product to life and introduced SleepBelt to the market in 2013. Within five weeks of launching, we received our first hospital inquiry, and an endorsement from la Leche League International. Based on clinician feedback, we made some slight alterations to the original product, and developed the more hospital-friendly Joeyband by SleepBelt. Having officially launched as a clinical product less than two years ago, Joeyband is now used in 100+ hospitals worldwide. The benefits of STS are numerous – it is linked to increased breastmilk production, better bonding, reduced post-partum depression, better infant sleep, temperature regulation, and brain development. The clinical

evidence is so strong, that the World Health Organization recommends STS for all newborns, while the Baby Friendly Initiative calls for 60 minutes of STS within the first hour of life – a simple act that can be tricky in certain scenarios… like the OR. “New practice is to put the baby skin-to-skin immediately after delivery, but that gets a little dicey in the OR. We can use the Joeyband to secure the infant to mother’s breast and the babies will settle right down and if positioned at the right angle will nuzzle over and actually initiate feeding while the doctors finishing on the other side of the drape,” says Liz Seaman, RN, BSN, IBCLC, CCE of Bridgeport Hospital. As part of linen prep, the Joeyband is laid out on the table under the mother’s back, above the sterile field. Once the baby is placed on her chest, the band wraps around and secures to the side with industrial-strength Velcro, keeping baby snug and secure – through repair, transport, and into recovery. Even with routine births, STS is not without its hurdles – mom is exhausted, possibly medicated, and may be physically unable to hold her baby in proper position for the recommended time, and babies are at risk of falling…

both out of position, or onto the floor, putting the infant at risk for skull fracture or suffocation. Additionally, Joeyband can help support extended kangaroo care in the NICU. The design easily supports twins, is gentle enough for micro preemies, and doesn’t interfere with medical lines.

Joeyband by SleepBelt is enhancing the birth experience – patient satisfaction scores are increasing, as parents are provided a simple tool to make the first 24-hours of life easier, safer, and calmer. This simple product is well on its way to becoming standard of care in birthing hospitals everywhere and it H started right here, in Canada. ■

Hayley Mullins is the Toronto-based co-founder & inventor of Joeyband and its retail counterpart, SleepBelt.

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AUGUST 2017 HOSPITAL NEWS 19

PAEDIATRICS

SickKids Children’s Council continues tradition of patient leadership

By Jessamine Luck ithin The Hospital for Sick Children (SickKids) there is a unique group of 16 changemakers who share their input from the frontlines of the hospital. They make up the SickKids Children’s Council and on June 6 they were recognized for their efforts to make SickKids a better place for patients and families at the End-of-Year Celebration for the Children’s Council and Family-Centered Care Advisory Council. The SickKids Children’s Council has been bringing the patient voice to the inner workings of SickKids for 17 years. The Council currently has 16 members ranging in age from 10-18 years and this year, for the first time, the group was open to siblings of patients to better understand their unique perspectives. Child Life Specialists provide administrative support to the Council, which is modelled after high school student councils.

20 HOSPITAL NEWS AUGUST 2017

Past and present Council members have weighed in on such far-reaching initiatives as the inpatient meal program, the SickKids Foundation’s VS campaign, the design of Marnie’s Studio and patient events. This year they have established an orientation manual for new child and youth advisors, contributed content for videos on AboutKidsHealth.ca and helped plan the annual teen prom. At the End-of-Year Celebration, Council members received recognition certificates before attending the final Children’s Council meeting of the year. “The Children’s Council’s engagement and participation is at the core of the model of care in which SickKids as an organization continues to strengthen,” says Pam Hubley, Vice President, Education & Learning Practice, and Chief, International Nursing. “We appreciate the time and energy the Council has

given over the last year, to respond to emails, provide an opinion, or pose a question to ensure we are considering all possibilities that may affect the process of how we care for kids.” The ceremony and subsequent final meeting were bittersweet because, this year, four Council members are turning 18 and graduating from SickKids. One such grad, Tobin, 17, who has been on the Council since 2011, says the Children’s Council has added a different perspective to the place where he has spent much of his life since he was two years old. “As a patient or sibling you see the immediate care to yourself and you see the hospital at face value, but when you’re on the Children’s Council you get an inside scoop on what’s going on,” he says. “In a way it’s relaxing and fun.” For Vanessa, 16, the highlight of the Children’s Council has been the

support it has offered her. “Being in a setting where there are both patients and siblings of patients in a room sitting down and talking about their story has made me feel less alone,” she says. “It’s made me become a little bit more grateful because there are people who are going through worse things than I am.” Interacting with other kids is one of the recurring highlights for Council members. “I remember when I was a little kid, looking up to older patients and now that I’m five months away from graduating I’ve appreciated seeing the impact that I now have on little kids,” Tobin says. “The friendships you form here are different from the kind you would normally have at school.” Andrea Fretz, a Child Life Specialist who oversees the Children’s Council, can also feel the energy in the room while working with the Council memwww.hospitalnews.com

PAEDIATRICS The SickKids Children’s Council 2016-17. bers. “Facilitating the Children’s Council during their meetings is an easy task as their engagement and participation is so passionate,” she says. “They view their voices seriously and know how important Children’s Council is. They recognize that it really is at the centre of the model of care which SickKids as an organization continues to strengthen.” Many of the current SickKids Children’s Council members are looking forward to another year of providing insight into crucial hospital projects. Some even hope to continue their involvement after they graduate. “I’m planning on coming back next year and hopefully until I graduate,” says Vanessa. “Hopefully when I graduate I can also be part of the Family-Centered Care Advisory Council and continue to share my input and be part of building a better community within the H hospital.” ■ Jessamine Luck is a Communications & Public Affairs intern at SickKids.

Canadian babies and toddlers are

heavier and longer than WHO Child Growth Standards ealthy Canadian infants and toddlers are heavier and longer than the World Health Organization (WHO) Child Growth Standards (CGS) according to a new study by researchers at the Institute for Clinical Evaluative Sciences (ICES) and St. Michael’s Hospital. In 2006, the WHO released universal CGS, intended to describe the optimal growth of children. The WHO Multicentre Growth Reference Study took place between 1997 and 2003, and included children from Brazil, Ghana, India, Norway, Oman and the USA, who were deemed to be free of health or environmental constraints on growth.

“Measuring a child’s weight and height is an important and routine aspect of monitoring early growth, but the WHO CGS may not reflect the growth of healthy Canadian children,” says Dr. Joel Ray, lead author on the study and a researcher at ICES and the Li Ka Shing Knowledge Institute of St. Michael’s Hospital. The study published last month in Paediatric and Perinatal Epidemiology compared the WHO-CGS to the postnatal growth of 9,964 healthy Ontarian children up to 2-years-old between April 1, 2002 and March 31, 2013, including various feeding practices and maternal place of birth.

The study found: • Canadian children were markedly longer than the WHO-CGS before 18 months, regardless of feeding practice. • Canadian children had a higher 50th percentile weight at birth, and again, after 6 months. • By age 2 years, the 50th percentile weight of Canadian males was 823 grams heavier than the WHO-CGS 50th percentile. The researchers add that the differences in percentiles of weight, length and BMI of young Canadian children compared to the WHO-CGS, regardless of infant feeding practice may impact how the “normal” growth of Canadian children is interpreted. ■ H

PAEDIATRICS

Congenital heart defect captures global spotlight By Lianne Castelino yes welling with tears and voice cracking, late-night Hollywood talk show host Jimmy Kimmel recently shared a raw, intensely personal account of how the birth of his son on April 21 slipped from wonder to worry after the newborn was diagnosed with a congenital heart defect called Tetralogy of Fallot with pulmonary atresia. The cardiac condition is the field of research of Dr. Rachel Wald, cardiologist, Peter Munk Cardiac Centre (PMCC), University Health Network (UHN). She is among several global medical experts who are part of the oldest and largest adult congenital heart disease program in the world, housed at PMCC and Toronto General Hospital, and led by Dr. Erwin Oechslin, cardiologist. In a Q&A, Dr. Wald, describes Tetralogy of Fallot, which results from four heart defects that begin in-utero, and which require specialized life-saving surgery within the first few days of life. Q: Describe the evolution in the diagnosis, treatment and prognosis of babies born with Tetralogy of Fallot and the timeline within which this evolution has occurred? A: Tetralogy of Fallot (TOF) is an eponymous term describing a cluster of four congenital cardiac abnormalities which develop in fetal life. The condition occurs in 33 of 100,000 livebirths and results in decreased flow to the lungs. It is the most common explanation for a cyanotic (blue) infant. The first breakthrough in management of this previously fatal disease occurred in 1945 when Drs. Blalock, Taussig and Thomas created a shunt to deliver augmented blood flow to the lungs. The first full surgical repair occurred in 1954. Since that time, vast improvements in pediatric cardiac surgery have translated into enhanced survival. Today, for the first time in history, adults with repaired TOF outnumber children. At present, the diagnosis of tetralogy of Fallot is often made in fetal life, full surgical repair typically occurs at six months of age, and approximately 90 per cent of babies who are repaired can be expected to live into their fourth decade of life and beyond. Q: What interests you most about this specific condition, your area of clinical interest and research?

22 HOSPITAL NEWS AUGUST 2017

A: More than any other form of congenital heart disease, TOF has seen the greatest advances in surgical management, development of percutaneous technologies and application of novel cardiac imaging applications. Despite being one of the most common forms of congenital heart disease seen by an adult congenital cardiologist and the most common

condition requiring re-operation in adult life, important questions regarding the appropriate clinical management for this population remain unanswered. One of the most critical questions to answer is when to offer pulmonary valve replacement surgery to stop complications from pulmonary valve leaking (which is a ubiquitous con-

sequence of Tetralogy of Fallot repair in childhood). Appropriate timing of pulmonary valve replacement, as guided by cardiac magnetic resonance imaging, is the focus of my research and provides an exciting interface for various disciplines, including adult congenital and pediatric cardiology, cardiovascular surgery and cardiac H imaging. ■

Lianne Castelino is a Senior Public Affairs Advisor at Peter Munk Cardiac Centre, University Health Network.

Paediatricians should think twice before routinely testing for respiratory viruses By Caitlin Johannesson n 2014, more than 2,000 kids who visited SickKids Emergency Department with respiratory symptoms were given an invasive and uncomfortable nasopharyngeal swab test. This is when a doctor or nurse inserts a long swab into the nostril to the back part of the nose to collect a sample of cells. The swabs are sent to the lab to test for six common respiratory viruses, but the results come back the next day, often after patients have already been discharged from the Emergency Department. With no set process for communicating positive or negative results for this test, the results generally did not impact the child’s care. With an increased emphasis on ‘choosing wisely’ and reducing unnecessary medical tests and therapies across the medical field, paediatricians at The Hospital for Sick Children (SickKids) say it is not good enough to ‘do’ these tests just because we ‘can’. The team examined the benefits and limitations for this specific type of test and reviewed the scientific evidence as to when it is actually helpful in improving patient care. The review, including their recommendations, was published in the July 3 advance online edition of JAMA Pediatrics. Most viral respiratory illnesses can be diagnosed clinically based on the child’s symptoms (for example, runny nose, cough, nasal and chest congestion), but with more sophisticated and sensitive tests available, frontline clinicians frequently order tests to identify the specific offending virus.

“While the number of testing options has grown rapidly, the same attention has not been given to deciding how and when these tests can add value to the care of our patients. Just because the test is available, doesn’t mean we should automatically order one, especially since we know that for the majority of healthy children the result will have no impact on their care,” says Dr. Jeremy Friedman, senior investigator of the review and Associate Paediatrician-in-Chief at SickKids. The review describes some of the common rationale used to justify respiratory viral testing but found poor evidence to support these rationales. Unsupported rationale includes: • to reduce the number of lab blood tests and chest x-rays performed, as well as unnecessary antibiotic use • to reduce the length of hospital stay • to offer prognostic information on length of the illness, and a confirmed diagnostic label for the physician and the family • to reduce healthcare costs

The team emphasized that there are clinical scenarios where respiratory viral testing can inform treatment decisions and improve overall patient care and therefore should be seriously considered. These examples include children with compromised immune systems, those at risk for influenza-related complications, children admitted to intensive care units, and infants with fever younger than three months old. “We hope this review helps health care providers make better decisions and think twice before ‘checking the box’ for a nasopharyngeal swab on the list of possible investigations,” says Dr. Peter Gill, lead author of the review and senior paediatric resident at SickKids. As part of SickKids Choosing Wisely initiatives, SickKids has reduced nasopharyngeal testing for typical respiratory viruses in the Emergency Department by greater than 80 per cent since 2014. This paper is an example of how SickKids is contributing to making Ontario Healthier, Wealthier and Smarter. H www.healthwealthiersmarter.ca ■

Caitlin Johannesson is a communications officer at The Hospital for Sick Children. www.hospitalnews.com

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ike all professions, the healthcare industry iss becoming increasingly digital. igital. Today, those working in the healthcare sector need easy access to information in any location, from the hospital bedside and consulting room to the administrative office. They want quick – and secure – ways to read d and update patient data electroniically, as medical records rapidly shift hift from paper to digital storage. In the past year, for example, nearly 162,000 2,000 clinicians across Canada were active ve users of electronic health records – more than double the number of users just ust three years ago. And for years, healthcare proofessionals and other device users have wanted an easy-to-carry tablet that could also be used as a reliable laptop. aptop. Enter Samsung’s Galaxy Book, a flexible new hybrid device for people who want a high-quality tablet that doubless as a lightweight portable PC – with Samsung’s innovative screen technology. gy.

For healthcare professionals who need to maximize productivity in an increasingly mobile working environment, this recent Samsung option offers the capacity for high-efficiency output with maximum portability and quick Internet connectivity from virtually any location. Whether doing hospital rounds, attending scientific sessions, tapping into telemedicine, or taking a moment to catch up on CME, those in the healthcare sector will find the Samsung Galaxy Book a product that keeps pace with their mobile working environments. “There’s an increasing shift toward mobile productivity, and that’s why we’re excited to launch this 2-in-1 device that combines the power of a PC with the mobility of a tablet,” says Shrey Thakrar, Director and Category Head, Mobile Division, at Samsung Electronics Canada Inc. “The Galaxy Book is truly built for professionals on the go and enables them to work from anywhere.” www.hospitalnews.com

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and work hours,” says Thakrar. Travelers working on the road or attendees at conferences and workshops can take notes at all-day sessions without stopping stopp to recharge.

Software advantages Sof Healthcare-sector employees will He Windows 10 feature of the find the t Samsung Galaxy Book makes it easy to Samsu compile reports and databases and crecomp worksheets, charts, and presentaate w tions using its smooth, easy-touch keyboard with island-style keys. The book is ideal ide for quickly accessing treatment information or drug contraindicainform tions and updating medical records at the bedside. The screen also permits viewing aat different angles with no colour loss, los which can be critical for the accurate interpretation of medical imaccur ages. Users can zoom in on images to make notes using text as well as write comments or draw diagrams with the comm improved S Pen. The pen is designed to impro provide a precise, natural-feeling writprovid experience. “You can even quickly ing ex jot something down while the screen is locked,” says Thakrar. The Air Command feature gives users fast access to S Pen functions and lets them easily share their creations online.

The 12-inch Samsung Galaxy Book combines heavy work power and lightweight mobility. Its detachable backlit keyboard with stand offers enhanced functionality with no recharging required. When work is done, the sleek 754-gram unit quickly converts from notebook to tablet. In addition to a fast-charging battery and an advanced pressure-sensitive S Pen, the model comes with a built-in Microsoft Windows 10 operating system and also features Samsung Flow for seamless interface between wireless devices.

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The battery on the Samsung Galaxy Book delivers laptop power without the worry of lag. In a single charge, the 12inch model supplies up to 11 hours of battery life*, and the smaller 10.6-inch version up to 9 hours. “This technology means you can fully charge your device in less than three hours, which is ideal when gearing up for long commutes

Thanks to its stereo speakers, the 12-inch book delivers exceptional sound, a useful feature for healthcare professionals when listening to detailed medical podcasts and video presentations. High-quality audibility makes it practical to attend medical meetings and professional conferences H remotely. ■

The 12-inch model also features two USB Type-C ports for additional accessories and is equipped with Bluetooth 4.1, allowing smooth connectivity to wireless accessories. With the Samsung Flow feature, users can pause an activity on a Samsung smartphone and pick it up from the same point on the Samsung Galaxy Book. “You can also unlock your Galaxy Book with your smartphone and change devices as you need to, which is great if you’re going between meetings and appointments,” Thakrar says.

Enhanced security The 12-inch Samsung Galaxy Book offers the security that all healthcare-sector professionals require. The model comes preloaded with Microsoft Windows PRO, with embedded security features, such as encryption, maintain the integrity of each device and protect sensitive medical information and patient data from today’s security assaults.

AUGUST 2017 HOSPITAL NEWS 23

SAFE MEDICATION

Risky business: An analysis of high-risk processes in community pharmacies By Adrian Boucher and Certina Ho lthough pharmacy professionals and healthcare organizations aim to provide error-free health care, medication incidents are often inevitable. Medication incidents include known, alleged or suspected medication errors that reach the patient (e.g., incorrect drug, quantity, dose, or patient) and may have significant negative implications to patients and healthcare professionals. Despite socio-technical advances in pharmacy practice, the dispensing process remains largely a high-volume, manual operation that may be prone to medication incidents. A number of high-risk processes are associated with increased risk of errors and require high-leverage, effective, and system-based strategies (Figure 1) to ensure they are performed accurately and safely. The Institute for Safe Medication Practices Canada (ISMP Canada) performed a multi-incident analysis to examine medication incidents causing harm in community pharmacy. Incidents were retrieved from ISMP Canadaâ&#x20AC;&#x2122;s Community Pharmacy Incident Reporting (CPhIR) program from October 2009 to May 2017. A total of 971 incidents were reviewed independently by two analysts to identify common themes and contributing factors. We identified the following three high-risk processes in pharmacy practice.

Table 1. Recommendations to Prevent Medication Incidents Related to High-Risk Processes in Pharmacy Practice Summary of Recommendations

Aim for high-leverage, effective, and system-based strategies

Hierarchy of Effectiveness

Implement barcode scanning to ensure correct selection of medication.

Automation and Computerization

Develop standardized procedures and documentation for high-risk processes.

Simplification and Standardization

Perform independent double checks throughout all steps of the medication-use process.

Reminder, Checklists, Double Checks CHECKS

Ensure staff members are not interrupted when performing a high-risk process.

Rules and Policies

Ensure designated staff members are adequately trained and equipped to perform high-risk processes.

Education and Information

Figure 1

lenge. In addition, methadone is considered a high-alert medication and has been associated with an elevated risk of accidental overdose. Between 2006 and 2008, methadone was involved in 15 per cent of opioid related death and accounted for the highest relative per-

e / Mo Less Effective More Feasible

2. Compliance packing or multimedication compliance aids preparation

1. Methadone maintenance therapy Incident Example: A patient ingested a higher dose of methadone (110 mg) than his intended dose (30 mg). The incident was discovered when another patient arrived for his dose, but it had been accidently given to a previous patient. Although the benefits and effectiveness of methadone maintenance therapy are well-documented, the safety of methadone dispensing in the medication-use process continues to be a chal-

More Effective / Less Feasible

centage of accidental death in Ontario. We identified a number of contributing factors associated with methadone related errors, including confirmation bias, frequent dose changes, pre-pouring of doses, and knowledge deficit of healthcare providers.

Incident Example: A patient noticed that he had extra pills in his compliance pack and notified the pharmacy. Upon further investigation, it was determined there was a Rosuvastatin 10 mg tablet in both the AM and PM slot; and it was supposed to be only in the PM slot. Compliance packs or multi-medication compliance aids are commonly prepared by community pharmacies to help patients organize their medications according to the date and time of administration. They have been found to have positive effects on adherence and disease management, as well as a reduction in patient and caregiver stress. However, one study found that manual packing of multi-medication compliance aids was associated with an error rate of approximately seven perc cent of packs, with the most common errors involving incorrect halving of tablets (49.1%), omission of a medication (22.0%), and inclusion of an extra dose (9.8%). Continued on page 31

Adrian Boucher is an Analyst at the Institute for Safe Medication Practices Canada (ISMP Canada) and a PharmD Student at the Leslie Dan Faculty of Pharmacy, University of Toronto; Certina Ho is a Project Lead at ISMP Canada. 24 HOSPITAL NEWS AUGUST 2017

www.hospitalnews.com

EVIDENCE MATTERS

Topical NSAIDs:

Right where it hurts By Anna Liang e’ve all likely experienced a fall or injury that caused us some pain. Whether a strain, a sprain, or muscle pain, it’s one of the most common reasons for visiting an emergency room or seeing a doctor or other healthcare professional. And although acute pain doesn’t usually last long, if not treated properly it can turn into longer-term, chronic pain. But how do we effectively treat the muscle pain that follows an accident or injury? We’ll most likely look for a pill, either a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen, or another over-the-counter option, like acetaminophen. These are, in fact, the recommended first-line treatments for acute musculoskeletal pain, which is short-term muscle or bone pain lasting less than three months. If these aren’t enough, stronger painkillers can be prescribed, including weaker opioids like tramadol or codeine, or stronger opioids like morphine or oxycodone. However, all of these pain medications come with the risk of serious side effects. High doses of NSAIDs have been linked to increased gastrointestinal and cardiovascular disease risk, high doses of acetaminophen with liver damage, and tramadol overdoses with brain damage. Long-term opioid use is also linked to addiction, and even an increased sensitivity to pain. As opioid prescriptions rise year by year in Canada and the country grapples with an opioid crisis, there is a growing need for alternatives to treat acute musculoskeletal pain. This is where topical NSAIDs might come in. These medications are applied on or close to the site of pain or injury. This delivery method allows the drug to be absorbed directly and avoids having the entire body exposed to the medication. This could potentially reduce the risk of side effects and of damage to other parts of the body. Topical NSAIDs are available over-the-counter and by prescription as gels, creams, patches, or other formulations.

www.hospitalnews.com

Topical NSAIDs are an attractive option for treating acute muscle pain. But do they work? And how do they compare with other treatment options? CADTH set out to find the evidence to answer these questions and to help patients and healthcare providers better understand the role of topical NSAIDs in the treatment of acute muscle pain. CADTH is an independent, not-for-profit agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures to deliver a comprehensive review of the evidence to-date. CADTH reviewed the research that has been published on the effectiveness of topical NSAIDs compared with opioids to treat acute pain. The review screened hundreds of articles and selected four relevant reports that met the strict selection criteria. Two reports analyzed multiple trials and found that most patients reported that their pain was reduced by over 50 per cent when using topical NSAIDs in gel, plaster, and cream formulations. Another trial showed that patients had to wait a significantly shorter time for pain relief after applying a topical NSAID patch compared with receiving no active treatment. Overall the evidence showed that topical NSAIDs are effective for acute musculoskeletal pain relief, and do not cause serious side effects. Minor side effects, such as skin irritation, were rare. However, the review did not find any studies directly comparing topical NSAIDs to opioids for acute musculoskeletal pain, or for using the topical NSAIDs to reduce the use of opioids. As a result, it’s not known how topical NSAIDs compare with opioids to treat acute muscle pain. So what does this mean for patients with acute muscle pain and their healthcare providers? Well, it’s an all-too-familiar refrain, but more studies comparing the treatments for acute muscle pain are needed to understand which treatment options are the most effective. In the meantime, topical

NSAIDs are at least one effective, evidence-based, treatment option. To learn more about alternatives to opioids for pain treatment, visit www. cadth.ca/opioids and www.cadth.ca/

pain. Learn more about CADTH by visiting our website at www.cadth.ca, follow us on Twitter @CADTH_ACMTS, or speak to a CADTH liaison H officer in your region. ■

Anna Liang, BSc is a summer student at CADTH.

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AUGUST 2017 HOSPITAL NEWS 25

FROM THE CEO’S DESK

Caring Safely:

Reliability and resilience By Dr. Michael Apkon s leaders, our first commitment is to keep patients and staff safe – no straightforward task. All complex systems fail predictably unpredictably. Healthcare delivery depends on a complex system, individuals, and teambased performance. Failures are too common with nearly four per cent of people admitted to Canadian Hospitals suffering some sort of harm – sometimes significant preventable injury or death. While harm can result from departures from practice standards, most result from complex circumstances that make it easier to err and harder to intercept paths towards harm. The Hospital for Sick Children (SickKids) has long focused on improving safety of care. Indeed, our clinicians have created tools supporting safety, now widely used internationally. Moreover, outcomes for children undergoing treatment in many programs are among the best compared to peers. Yet, when looking carefully, we saw that unexpected poor outcomes happen and sometimes result from preventable failures. In 2015, we began using a standardized way to detect and analyze unexpected harm to understand how frequently people suffered moderate or serious harm from deviations from accepted practice standards – events we call serious safety events (SSEs; Healthcare Performance Improvement, LLC). We also compared our results to more than 100 US children’s hospitals collaborating to improve safety in the Solutions for Patient Safety Network. (www.solutionsforpatientsafety.org). What we found was somewhat reassuring – we provided similarly safe care as many peers. However, some organizations had reduced SSEs by more than 80 per cent, by adopting a comprehensive and robust safety program. In fact, I had led such an initiative in my former institution where the rate of serious safety events fell by more than 80 per cent over three years.

Dr. Michael Apkon With the data about our performance in hand and knowing other organizations improved safety substantially, in 2016 we launched “Caring Safely” to reduce preventable harm to children by 2/3 and preventable employee harm by 20 per cent within three years. We also became the first international participant in Solutions for Patient Safety, believing we could improve far faster working with other organizations. We’ve been fortunate to find partners close to home as well – partnering with University Health Network to create Caring Safely and learning from each other. We also continue to partner with the other children’s hospitals in Canada, several of which have joined Solutions for Patient Safety. What we’ve learned is safety is about staying out of trouble and also getting out of trouble quickly when things don’t go as intended. Staying out of trouble

depends on reliably doing things the safest way by combining standardization (for example, taking the same steps every time as a pre-procedure checklist to prevent infections and errors) and more mindful practice to avoid slips, lapses, and cognitive errors during mundane and complex tasks. It also depends on maintaining situational awareness about tasks at hand and factors that might influence performance. Getting out of trouble – having resiliency to recognize and adjust to deviations from expected paths – also depends on a more mindful practice as well as exceptional teamwork and communication. Since starting, we’ve trained over 6000 individuals – ultimately aiming to train our entire workforce – to use safety behaviours that promote mindful practice, improved communication, and teamwork. We’ve also adopted practices aimed at learning from

those times when situations don’t go as planned – particularly when we identify serious preventable harm – as well as ways to reinforce safety at every level including having families participate on our safety committees. Although we still have work left to do, we see progress: a 50 per cent decrease in SSEs and a more than 20 per cent reduction in injuries to staff. Along with the cultural transformation created by Caring Safely, we’ve learned leaders can expect to create and manage some tensions. First, teamwork requires appropriately asserting concerns and respectfully challenging information when necessary. That creates interpersonal conflict when confrontation is unfamiliar. Reinforcing behaviours that support open communication, respectful challenge, and conflict resolution is an important leadership role. Second, discussing errors or failures, particularly when a child is injured, is traumatic, especially for caregivers involved. However, learning and improvement requires transparency. Supporting caregivers through the experience of falling short is an important leadership responsibility that helps establish a fair and just culture where system contributors are acknowledged and people can be accountable for choices they make, recognizing that the best of people can make tragic mistakes. Third, as deviations from practice standards are identified during safety event reviews, we may learn that choices to deviate are the norm and driven by failures to establish clear accountability or address systems factors that make conforming to standards difficult. We chose to focus on safety, not because we believed it easy to improve. Rather we chose this focus because we recognize that reliability and resilience are keys to improving not only safety, but all aspects of performance. While we set an initial goal of reducing preventable harm by 2/3, our ultimate aim is to eliminate preventable harm over a H set of achievable steps. ■

Dr. Michael Apkon is President and CEO at The Hospital for Sick Children. 26 HOSPITAL NEWS AUGUST 2017

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FOCUS

Erasure of negative memories one step closer to reality By Shawn Hayward cientists have known for some time that a memory is stored in the brain through changes in the strength of particular synapses, the structures that pass signals between neurons. However, how the change in strength persisted remained a mystery. Solving this mystery has important implications for remedying neurological and psychological disorders. A collaborative study by research groups from Columbia University Medical Center and the Montreal Neurological Institute and Hospital of McGill University (The Neuro) has improved our understanding of memory retention. Their findings could one day lead to therapies that alleviate anxiety disorders and posttraumatic stress disorder (PTSD) by selectively erasing pathological memories. In 2006, neuroscientist Dr. Todd Sacktor and his colleagues at Downstate Medical Center were able to erase memories in mice by inhibiting a key enzyme named PKMzeta. Subsequent studies however found it was not so simple – mice that had PKMzeta genetically deleted could still form normal memories, as other molecules could compensate for the loss. While this was frustrating for scientists trying to understand memory, it also posed an opportunity. If more than one molecule could maintain memory, maybe individual memories could be manipulated by targeting specific molecules. Dr. Wayne Sossin’s lab at The Neuro found that not only PKMzeta, but a family of related molecules could maintain memory in a mollusk called Aplysia california. Researchers often use Aplysia to determine the cellular and molecular bases of simple forms of learning and memory because they have large neurons and a simple, easy-to-manipulate nervous system. The results generally parallel those found in vertebrates. Dr. Samuel Schacher and Research Associate Jiangyuan Hu at Columbia University Medical Center found that it was possible to reverse the cellular

Community stroke rehabilitation team getting patients

back on their feet By Anne Kay n 2014 a series of medical events turned Cora King’s world upside down, but the Community Stroke Rehabilitation Team helped make her world right again. Cora, then 37, was living in a tranquil rural setting in Middlesex County, leading a busy life caring for her husband and two young boys and working at a Community Health Centre. She had the first inkling something might be wrong when she started dropping things and had trouble moving her legs. After many diagnostic tests, Cora was given the devastating news she had a brain tumour. Next she had a seizure, then pneumonia, and finally a stroke. She was gravely ill, but fine medical care, the love and support of her husband, and her steely determination carried her through. Once Cora’s health stabilized, she continued her recovery at St. Joseph’s Health Care London’s Parkwood Institute. When she was discharged home in January 2016 the Thames Valley Community Stroke Rehabilitation Team (CSRT) swung into action. “The healthcare professionals on the CSRT provide intensive rehabilitation in clients’ homes so they can achieve their rehabilitation goals,” explains occupational therapist (OT) Martha Scott. “We take a very holistic approach to care, so clients can become more independent and reintegrate into their community.” As an OT, Martha helped Cora relearn activities of daily living such as dressing and showering. The physiotherapist helped Cora learn to walk again, and the speech language pathologist and OT assisted her with thinking skills such as memory and scheduling.

storage of two simple forms of memory (associative and non-associative) in Aplysia californica with different types of manipulations, suggesting that different molecules could maintain each memory. Associative memory occurs when we create links between unrelated items, like a bell sound and recess or dismissal. Non-associative memory is the generalized reaction to certain stimuli caused by previous experience, such as anxiety caused by a traumatic event. The Schacher and Sossin labs then teamed up to determine if distinct memories use different members of the PKM family. The researchers stimulated two sensory neurons of Aplysia, both having synaptic connections with the same motor neuron, one to induce associative memory, and another to induce non-associative memory. They found that by targeting specific variants of PKM in the motor neuron, they could erase the associative and non-associative forms separately, because the variants responsible for strengthening the synapses of each of the two sensory neurons are different. In addition, they found that specific memories are also erased by targeting distinct variants of other molecules that either protect specific

PKMs from degradation or participate in the generation of specific PKMs. Their findings are described in a paper published on June 22, 2017 in Current Biology. It demonstrates that different forms of memory co-exist in the same neuron and each form can be manipulated separately. The paper identifies new facts about how memories are stored and demonstrates ways to selectively erase them, with a goal to one day treating conditions like anxiety disorder and PTSD. Memory erasure has the potential to alleviate PTSD and anxiety disorder by removing the non-associative memory that causes the maladaptive physiological response. By targeting the exact molecules that maintain non-associative memory, drugs may be developed that can treat anxiety while not affecting the patient’s normal memory of past events. “Our work demonstrates that there are diverse mechanisms by which neurons maintain memories in the brain and provides hope that some day we will be able to selectively remove pathological memories.” says Dr. Sossin. This study was funded by a CIHR grant to Dr. Sossin and an NIH grant H to Dr. Schacher. ■

Shawn Hayward is a Communications Officer at Montreal Neurological Institute and Hospital (The Neuro). 28 HOSPITAL NEWS AUGUST 2017

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FOCUS

“THE HEALTH CARE PROFESSIONALS ON THE CSRT PROVIDE INTENSIVE REHABILITATION IN CLIENTS’ HOMES SO THEY CAN ACHIEVE THEIR REHABILITATION GOALS” The therapeutic recreation specialist taught her activities like colouring and knitting to help retrain hand dominance. The social worker supported Cora and her husband in addressing their new family roles, and the nurse provided education about medications and healthy lifestyle choices. Finally, the rehabilitation therapist practiced therapy plans with Martha so she could meet her goals. “I believe one of the reasons Cora had an incredible recovery is because she is so motivated,” says Martha. “My desire to be independent

outweighed my frustration with my physical limitations,” says Cora The members of Cora’s church were supportive and offered to alter a pew to fit her wheelchair. “I said no thank you; they were amazed when I walked into church with just a quad cane.” These days Cora is once again living a full life managing household chores, attending a day program, going to her children’s activities and socializing with friends and family. With her can-do attitude, Cora’s advice to others who have had a stroke is, “Never stop trying – if you H think you can you will.” ■

Anne Kay is a Communication Consultant at St. Joseph’s Health Care London.

With her right arm and hand affected by the stroke, Occupational Therapist Martha Scott, right, helps Cora King learn new way to do tasks such as washing dishes.

NURSING PULSE 0.076

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30 HOSPITAL NEWS AUGUST 2017

Every action has an environmental effect by Victoria Alarcon urses play a role in keeping our water clean by following the correct procedures to dispose of pharmaceutical waste. Registered nurse Kerrie Pickering knew something wasnâ&#x20AC;&#x2122;t right when she saw an empty IV bag hanging over the side of a hospital sink on the acute medical floor she was working on seven years ago. The bag â&#x20AC;&#x201C; which was full of the blood thinner heparin â&#x20AC;&#x201C; had been cut and drained, allowing the medication to enter the hospitalâ&#x20AC;&#x2122;s plumbing system, the first step in its journey to our water supply. â&#x20AC;&#x153;I was shocked,â&#x20AC;? says Pickering, who, in addition to studying nursing, has her bachelor of science degree in environmental studies, her masterâ&#x20AC;&#x2122;s degree in geography, and is starting her PhD on the relationship between the environment and health. Her education, coupled with the findings of research she started in 2001, has taught her that although many pharmaceuticals are removed through the wastewater treatment process, some still make their way into Canadaâ&#x20AC;&#x2122;s drinking water. After discovering the IV bag, Pickering went to investigate, asking several nursing colleagues what might have happened. A nurse confessed she had cut and emptied the bag down the drain. When Pickering asked her why, she said she didnâ&#x20AC;&#x2122;t know what else to do with it. â&#x20AC;&#x153;I think itâ&#x20AC;&#x2122;s such a good example of the lack of education,â&#x20AC;? said Pickering, noting that many nurses at that hospital were unaware of the correct protocol to dispose of pharmaceuticals. If nurses are aware, they can make a huge impact, she says. â&#x20AC;&#x153;(Nurses) can (encourage) their employers to start disposing of pharmaceuticals appropriately if theyâ&#x20AC;&#x2122;re not. They can be vigilant in their work areas,â&#x20AC;? she explains, adding that everyone in the hospital has a role to play. According to the College of Nurses of Ontario (CNO), nurses must know how to implement safe medication practices including bio-hazard preven-

tion when providing care to clients, self, other health workers, and the public. However, Pickering says nursing students â&#x20AC;&#x201C; including herself when she was a student in the early 1980s â&#x20AC;&#x201C; do not learn about hospital waste management in their nursing curriculum. They also donâ&#x20AC;&#x2122;t spend enough time on this during hospital placements. â&#x20AC;&#x153;There is no time to devote to this,â&#x20AC;? says Pickering, suggesting nursing schools and hospitals are already under so much pressure to fulfill their other responsibilities, and that the environment can be forgotten. Edward Rubinstein, director of environmental compliance, energy and sustainability at Torontoâ&#x20AC;&#x2122;s University Health Network (UHN), believes hospitals must prioritize the environment. â&#x20AC;&#x153;Hospitals are dealing with health, and one of the biggest impacts on our health is the outside environment,â&#x20AC;? he says. â&#x20AC;&#x153;If weâ&#x20AC;&#x2122;re polluting and wasting its resources, weâ&#x20AC;&#x2122;re impacting our health.â&#x20AC;? At UHN, Rubinstein says the organization takes a proactive approach to education about the environment. Staff are notified about the different environmental policies through department meetings, group huddles, emails, posters, as well as one of their most effective communication venues, their environmental blog, Talkinâ&#x20AC;&#x2122; Trash with UHN, which informs staff about how they have a role to play in making the hospital more green. â&#x20AC;&#x153;We really focus on communication and engagement,â&#x20AC;? says Rubinstein. Nurses in hospitals can make a huge difference in the work they do every day, Pickering says, beginning with disposing of pharmaceuticals properly, and according to their hospitalâ&#x20AC;&#x2122;s policy. For health-care organizations such as UHN, drug disposal bins are available for nurses to drop off pharmaceutical waste such as partially filled syringes, pills, vials, and IV bags containing medications. Unopened IV bags and expired medications can often be returned to the in-patient pharmacy. Nurses can also educate colleagues about the procedures. In 2010, Pickering created a green team at her workwww.hospitalnews.com

NURSING PULSE place. A nurse on each floor volunteers to go around and remind staff about the different disposal bins available for waste, and which ones to use. As a green team member, Pickering would also replace wrong bins with the right bins on drug carts, and let her colleagues know why she was replacing it. She says the key was to do this in a non-confrontational way by introducing herself and explaining the differences between the bins. Pickering says she was considerate about the time of day she talked to colleagues, choosing the afternoon when most nurses at her hospital were available. â&#x20AC;&#x153;I would literally walk into the drug room with bins and postersâ&#x20AC;Ś saying â&#x20AC;&#x2DC;Hey, have you seen these posters before?â&#x20AC;&#x2122;â&#x20AC;? says Pickering, adding that the nurses she spoke with appreciated learning about the different bins and which ones to use to dispose of pharmaceuticals properly.

Nurses can also make a difference outside hospital walls. As part of the Registered Nursesâ&#x20AC;&#x2122; Association of Ontarioâ&#x20AC;&#x2122;s (RNAO) Ontario Nurses for the Environment Interest Group (ONEIG), Pickering has given online presentations to nursing students and included information in the interest groupâ&#x20AC;&#x2122;s newsletter about how pharmaceuticals enter the water supply, and how nurses can stop it. When speaking with the public, she explains that health professionals of all types can inform them about how they should be disposing of their medications by bringing them back to their nearest pharmacy for proper disposal at no cost. The public will pay attention when health providers tell them that expired or unnecessary drugs should never be flushed down the toilet, she says. â&#x20AC;&#x153;If we keep our environment healthy, it does better, and we do better,â&#x20AC;? she says. â&#x20AC;&#x153;And H itâ&#x20AC;&#x2122;s doable in our everyday actions.â&#x20AC;? â&#x2013;

Victoria Alarcon is editorial assistant for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. This article was originally published in the March/April 2017 issue of Registered Nurse Journal, the bi-monthly publication of the Registered Nursesâ&#x20AC;&#x2122; Association of Ontario (RNAO).

Risky business

Continued from page 24

The contributing factors associated with compliance packs incidents include frequent changes to drug regimes, preparation of packs several weeks prior to pick-up or delivery, and inadequate verification of current orders with multi-medication compliance aid contents.

3. Preparation of compounds or compounding Incident Example: A patient reported that the menthol compound he/she received caused burning. The pharmacy technician who prepared it did not get another staff member to double check the amount of menthol measured. After re-compounding the prescription, the resulting compound had a weaker menthol smell. Compounds are most frequently prepared for patients who require a dose or dosage form that is not commercially available. They often require special-

ized knowledge, equipment, and sufficient time to prepare. Although case studies related to compounding errors were well reported in the literature, limited information is available on the rates and types of incidents that occur in community pharmacies in Canada. In this analysis, we identified contributing factors that include inadequate staff training, expertise, and equipment, and inadequate standardized process for compound preparation. The medication distribution system is generally safe. Yet, it is prone to medication incidents that may adversely impact patient safety. By systematically examining and reviewing medication incidents, we have identified potential contributing factors and made recommendations to prevent similar errors from happening in the future (Table 1). This analysis highlights the importance of continuously reporting, analyzing, and sharing medication incidents to H improve patient/medication safety. â&#x2013;

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