Hospital News November 2020

Special: Canadian Society of Hospital Pharmacists Inside: From the CEO’s Desk | Evidence Matters | Special Focus: Medtech

November 2020 Edition

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FEATURED

Canada

lags in

adopting medical

innovation Page 22

THANK YOU FOR YOUR HEROIC EFFORTS  We’re so grateful for your tireless efforts and those of your fellow frontline workers as you all work so hard to keep Canadians safe and healthy. We’re staying home so that you too can stay safe!

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For years, Ontario’s nurses have been sounding the alarm that long-term care is broken. Why did it take a pandemic and a scathing report from Canada’s military for the government to take notice? The death of so many seniors was a tragedy that never should have happened.

Long-term care requires better funding, more staff, and higher standards. Our seniors and the people who care for them must be valued. Nurses care, and that’s why they’re still fighting.

STILL FIGHTING nursesknow.ona.org

Contents November 2020 Edition

IN THIS ISSUE:

Inhaled drug cocktail could block COVID-19

5

▲ Cover story: Canada lags in adopting medical innovation

22

▲ Model to project local COVID-19 numbers

8

▲ 7th annual Medtech Canada Supplement

COLUMNS

18

Editor’s Note ....................4 In brief .............................6 From the CEO’s desk .....16 Evidence matters ...........16 Safe medication ............39 Ethics .............................40 Long-term Care ...............43

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▲ Telepractice and equity

40

Special focus: Canadian Society of Hospital Pharmacists

30

Increased use of technology among older Canadians

44

COVID-19 shows how patient safety and health worker safety go hand in hand

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UPCOMING DEADLINES

Such stressors take a toll on the well-being and safety of our health providers. And that’s not good for patients.

Research has shown that organizational climate can significantly affect both patient and worker safety. A recent systematic review reveals a strong correlation between high levels of health worker burnout, often caused by work overload and a lack of empowerment, and worsening patient experiences and outcomes.

Compromises in patient safety rooted in organizational structures and culture can also cause anxiety and distress amongst health workers. Consider the well-documented dilemmas faced by workers in long term care where worker safety outcomes can be seen as an indicator of quality in nursing homes.

In many countries, including Canada, healthcare providers are facing increased risks of infections, violence, mistakes, guilt, stigma, illness and even death.

What needs to happen to ensure patient and healthcare worker safety?

Improved investments in health worker physical and psychological health and safety should be a national, provincial/territorial, and organizational priority for improving patient safety outcomes.

In fact, the World Health Organization (WHO) has called on governments to commit to urgent and sustainable action to ensure health worker safety and patient safety. Key suggested action areas include establishing synergies between health worker safety and patient safety policies, and the development and implementation of national programs for better occupational health and safety of health workers, including peer support programs.

Continued on page 6

DECEMBER 2020 ISSUE

JANUARY 2021 ISSUE

EDITORIAL: November 13 ADVERTISING: Display – November 22 | Careers – November 0

EDITORIAL: December 6 ADVERTISING: Display – December 11 | Careers – December 15

Monthly Focus: Year in Review/Future of Healthcare/Accreditation/Hospital Performance Indicators:Overview of advancements and trends in healthcare in 2020 and a look ahead at trends and advancements in healthcare for 2020. An examination of how hospitals are improving the quality of services through accreditation. Overview of health system performance based on hospitals

Monthly Focus: Professional Development/Continuing Medical Education (CME)/ Human Resources:: Continuing Medical Education (CME) for healthcare professionals. The use of simulation in training.

Human resource programs implemented to manage stress in the workplace and attract and retain healthcare staff. Health and safety issues for healthcare professionals. Quality work environment initiatives and outcomes.

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4 HOSPITAL NEWS NOVEMBER 2020

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By Ivy Bourgeault and Chris Power nother World Patient Safety Day has come and gone with great virtual fanfare. The theme for the World Patient Safety Day was one that should continue to resonate widely given the ongoing global pandemic: the important link between health worker safety and patient safety.

Healthcare providers around the world are engaged in actions intended to enhance health, yet they regularly put themselves at risk in order to care for their patients. Working in stressful healthcare environments can make this burden worse.

The COVID-19 pandemic brought these dangers to an entirely new level, revealing how risks to health workers risk patient health and safety in turn. Creating a safe space for healthcare workers has never been more important.

Today, health workers worry about being infected with the novel coronavirus themselves and contributing to the spread of the virus at work, at home, or in their communities. This adds to the stress we all share of managing work, family, and home life commitments, particularly when childcare and schools have been on hold or in flux, as well as elder care for aging parents.

Health workers have also had to work with limited access or adherence to personal protective equipment (PPE) and other infection prevention and control measures. They’ve had to be flexible and resilient in the face of ever-changing and evolving work policies and practices. They’ve also had to bear the burden of being seen as responsible for sub-optimal care or errors which could potentially harm patients and fellow health workers.

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NEWS

An inhaled drug cocktail could block COVID-19 The antibody-based treatment shows promise as temporary therapy against the virus

By Vivian Sum he immunotherapy based on antibody research being developed by Vancouver Coastal Health Research Institute researcher Dr. Horacio Bach could provide short-term protection against the novel coronavirus, SARSCoV-2. To date, COVID-19 – a disease that largely affects the respiratory system – has claimed the lives of over 870,000 people worldwide.

“One of the challenges we face with regards to a potential COVID-19 vaccine is that we do not know if it could offer long-term protection against reinfection,” says Bach. “Our system could offer an effective and safe therapy right away.”

Bach, study co-lead Dr. Ted Steiner and their team are developing single-chain antibodies that would neutralize proteins the COVID-19 virus employs to infiltrate cells – keys it uses to unlock cells in the body and destroy them.

This is no small feat, as there are millions of potential antibodies to choose from. While it may seem like finding a needle in a haystack, Bach and his team have already identified over 20 hopefuls since beginning their research in April.

“We have some promising antibody candidates already, and one in particular that is neutralizing the virus,” notes Bach.

INHALED ANTIBODIES COULD AVOID A CYTOKINE STORM

T

Researchers are using a novel approach involving a bacterial system to screen the antibodies. An antibody attached to a non-infectious virus is injected into a bacteria, and after a processing process, researchers check whether that blocks viral proteins used by COVID-19 to infiltrate host cells.

Several protective antibodies against COVID-19 are being sought, as the virus possesses a multitude of protein keys to unlock the body’s cells. The ideal therapy would contain an antibody cocktail that can guard against multiple lines of viral attack.

“The goal of this treatment is not to provide long-term immunity that a vaccine would,” says Bach, but one dose could shield against the virus for several hours or more until protective antibodies are processed and expelled from the body – long enough to catch a flight, go to an appointment or see a loved one.

Bach anticipates that this ground breaking approach will enter human trials by spring 2021.

Bach’s therapy has the potential to prevent a cytokine storm – when the body’s immune system goes into overdrive and starts attacking healthy cells, which can lead to inflammation and organ failure.

The novel coronavirus infects a certain type of cell, mostly primary airway epithelial cells. Once these cells are infected, white blood cell antibodies, called macrophages, attack the virus-containing cells and internalize them.

Problematically, COVID-19 also infects macrophages with its protein key, which can lead to a heightened

and potentially deadly immune response, or cytokine storm. “This is something that is unique to coronaviruses, as typically the macrophages would destroy the virus and not become infected with it,” says Bach.

Bach’s therapy could sidestep this problem by encapsulating COVID-19 with antibodies that would not infect macrophages, giving the body a leg up on slowing and stopping the disease.

“We hope that this treatment will help the immune system clear the COVID-19 virus from the body without inducing inflammation or a cytokine storm.”

The safety of the therapy also increases the likelihood that it could be approved faster than other potential therapies, says Bach. n H

Vivian Sum works in communications at Vancouver Coastal Health Research Institute.

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Safety Continued from page 4 WHO also calls on governments to protect health workers from violence in the workplace, as well as for the improvement of mental health and psychological well-being of the health workforce. Finally, we need to protect health workers from physical and biological hazards.

In the recent Speech from the Throne, the federal government stated that we owe an immense debt to our health care personnel. The pan-

demic has made clear why Canadians “need a resilient health care system.”

But for our health systems to stay resilient, we need to safeguard the health and well-being of our health workforce – from personal support workers, to homecare aides, to nurses and doctors, lab workers, and beyond.

Our health system is only as strong as our health workers. It’s time to care for the workers who care H for us. n

Dr. Ivy Lynn Bourgeault is a Professor of Sociological and Anthropological Studies at the University of Ottawa and the Lead of the Canadian Health Workforce Network. Chris Power is CEO of the Canadian Patient Safety Institute. www.hospitalnews.com

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IN BRIEF

COVID-19 recovery must address mental health and addiction crisis warn experts verything is not all right, warned Ontario’s leading mental health and addiction organizations in a meeting with Deputy Premier and Health Minister Christine Elliott and Associate Minister of Mental Health and Addictions Michael Tibollo. The group discussed the critical importance of embedding mental health and addiction as part of recovery efforts for the impact of COVID-19.

The pandemic of mental illness predated COVID-19 by decades. Mental illness, including substance use, is a burning hot issue right now. Before the onset of COVID-19 more than one million people in Ontario experienced mental health and addiction challenges every year. Ontarians were already facing up to 2.5 year wait times to access mental health and addiction services in some cases, often turning to emergency rooms in crisis.

The mental health of Ontarians is an economic issue. The pandemic of mental illness and addiction is affect-

E

OVERDOSE RATES AND OPIOID RELATED DEATHS HAVE INCREASED DURING THE MONTHS OF THE PANDEMIC BY UP TO 35-40 PER CENT ON A WEEKLY BASIS, ACCORDING TO ONTARIO’S CHIEF CORONER. ing Ontarians’ ability to work, earn an income, pay taxes, maintain stable housing and care for their families.

We are greatly concerned about the effects on generations to come if we do not embed sustained, mental health and addiction care as part of recovery efforts.

Ontario’s mental health and addiction leaders are critically concerned about the impact that COVID-19 has already had on Ontarians, in particular the trauma endured by front line professionals and those who have lost loved ones. Research shows that COVID-19 disproportionately impacts racialized and lower-income people. Overdose rates and opioid re-

lated deaths have increased during the months of the pandemic by up to 3540 per cent on a weekly basis, according to Ontario’s Chief Coroner. The most vulnerable, children and seniors, are at high risk, with some child and youth mental health centres already seeing a 20 to 50 per cent increase in the rate of demand since last year.

Providers of mental health and addiction services continue to advocate to the Ministry of Health and the Ontario government, asking that they reaffirm their commitment to develop and implement a comprehensive and connected system for Ontarians, investing $3.8 billion over 10 years.

This includes flowing $380 million in

immediate funds for new services before the end of the year, along with the release of an implementation plan that includes specific priority outcomes and accountabilities. This also includes multi-year funding to support and save the lives of those impacted by mental health and addiction issues.

Now is a critical time to invest the committed funding into the mental health of Ontarians, an investment that will pay both health and economic-related dividends for years to come.

In our meeting we stressed the importance of the Ontario government meeting its mental health and addiction commitment. We are concerned that two years after coming into government there is still no funding to reduce wait times for Ontarians waiting for mental health and addiction services.

We are calling for a recommitment to the government’s promise to invest $3.8 billion over 10 years to build a comprehensive and connected mental H health and addiction system. n

Canadian Drug Policy Coalition launches national dialogue series on the overdose crisis and COVID-19 ever before in Canadian history have communities confronted two concurrent public health catastrophes like the overdose crisis, fueled by a toxic drug supply, and a coronavirus pandemic that has uprooted the routines of daily life and society. At the heart of these converging crises are people who use drugs. COVID-19 has made everything worse for this community at a time when overdose deaths are rising across the country and individual health and safety is more precarious than ever.

In response to this unprecedented time, the Canadian Drug Policy Coalition at Simon Fraser University, in partnership with the Morris J. Wosk

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6 HOSPITAL NEWS NOVEMBER 2020

Centre for Dialogue, is launching Getting to Tomorrow: Ending the Overdose Crisis – 18 public health dialogues across Canada over the next two years aimed at identifying and moving towards solutions to the overdose crisis, in the context of COVID-19, by building consensus and shared meaning.

“The COVID-19 pandemic has exposed the illegal drug toxicity death crisis as a catastrophic failure of Canada’s current approach to drugs. Governments have moved mountains in response to the COVID-19 pandemic while a coherent pan-Canadian approach to over 15,000 overdose deaths in the past four and a half years has failed to materialize,” says Donald MacPherson, executive director of the Canadian Drug Policy Coa-

lition. “We hope the Getting to Tomorrow dialogue series will inform, engage, and inspire Canadians to become more involved in building a new approach to drugs based on principles of public health and human rights, and lead to improved health and safety for all in our communities.”

Getting to Tomorrow is also hoping to use learnings from the COVID-19 pandemic to improve Canada’s overdose response at a time when lives are being lost at an unprecedented rate. More specifically, Getting to Tomorrow has three main goals: 1. Accelerate the adoption of public health- and human rights-based drug policies to guide government responses to drugs in Canada

2. Empower decision makers and the public to take evidence-based actions by providing the latest research on policies that could end the overdose crisis 3. Engage the public in dialogue on issues related to substance use and drug policy The dialogues will happen virtually (open to invited attendees only) and will invite leaders from diverse communities, including people who use drugs, community and business leaders, government officials, First Nations, public health officials, and law enforcement, to share their stories of navigating the challenges of the overdose crisis during a time of pandemic and global instability. For more info: H www.gettingtotomorrow.ca n www.hospitalnews.com

IN BRIEF

Pan-Canadian initiative to evaluate and scale virtual innovations in youth mental health amidst COVID-19

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he Canadian youth mental health and substance use (YMHSU) system has moved rapidly over the past year to develop, accelerate and implement virtual responses to the COVID-19 pandemic in order to meet the needs of youth and their families.

Frayme launched the Virtual Innovations in Care (VIC) Grant program to support learning and understanding about the process of implementing effective virtual services. A total of eight evidence generating and innovative virtual solutions were chosen through an open call to receive funding and partner with Frayme to support the scale up, implementation, and evaluation of these innovations.

Atlantic Wellness – Circle of Care Program: At the onset of the COVID-19 pandemic, Atlantic Wellness worked to develop and implement virtual mental health services to ensure there was very little impact to youth during this crucial time.

Crossroads Children’s Mental Health Centre – Kids Come First: In response to COVID-19, Kids Come First partners are collaborating to deliver virtual mental health groups for children, youth and families, pooling together knowledge and resources to increase access to care.

Foundry – Foundry Virtual Care: Foundry launched drop-in counselling services via chat, voice or video calls in April due to COVID-19, followed

Clearing backlog caused by first wave of COVID-19

will require more than $1.3B additional funding

new study commissioned by the Canadian Medical Association (CMA) suggests at least $1.3 billion in additional funding is required to return to pre-pandemic wait times for six procedures. The report Clearing the Backlog: The Cost to Return Wait Times to Pre-Pandemic Levels quantifies the backlog resulting from the first wave of COVID-19 for six procedures, which together account for nearly 80 per cent of the diagnostic and surgical care provided in hospitals in Canada.

The analysis considers the volume and cost of the backlog caused by COVID-19 and the financial investment needed to return to pre-pandemic wait times within one year.

The report points out that wait times have increased by up to 75 days for cataract surgeries and 33 days for a CT scan.

The study found that all provinces will require at least 15 per cent more funding over baseline costs to return the wait times for all six procedures to pre-pandemic levels. The amount of additional funding needed varies by province because of factors such

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as accumulated backlog, capacity and the size of the population. The highest funding needed is in Ontario and Quebec because they have the largest populations, but PEI requires the largest percentage increase in funding.

The six procedures reviewed in the report are coronary artery bypass grafting (CABG), cataract surgeries, hip replacements, knee replacements, MRI scans and CT scans. The estimates do not include the impact on primary care services.

The following list provides the number of days to be made up to return wait times to pre-pandemic level as well as the additional costs to clear backlog: · CABG: 34.4 days: $103.3M · Cataract: 75.5 days: $357.4M · Hip replacement: 55.7 days: $77.4M · Knee replacement: 64.7 days: $101.2M · MRI scan: 52.0 days: $377.0M · CT scan: 33.1 days: $377.0M In a submission to the federal government in August, the CMA called on the government to create a one-time Health Care and Innovation Fund to resume health care services, bolster public health capacity and expand H primary care teams. n

by online peer support and workshops.

Foundry’s team will focus on the experience of youth accessing Saskatchewan Health Authority – Evaluation of Virtual Care in Youth Mental Health & Addiction Services: Youth Mental Health & Addiction Services provides therapy and outreach services to youth and their families.

Shibogama First Nations Council – Payahtakenemowin Youth Well-Being Program: This mental wellness program includes virtual cultural teachings from local Knowledge Keepers, live streamed traditional land-based experiences, and online safe spaces for social interaction with peers. The program also offers online therapy sessions with counsellors, including specialized services in expressive arts therapy.

Stella’s Place – Bean Bag Chat (BBC): BBC is a technology that offers text-based mental health support.

The platform consists of a mobile app

and an operator web portal. The app is available for service users to download for free on their iOS or Android device and allows young adults living in Toronto to engage in secure 1:1 chat sessions with Peer Support workers.

The Students Commission of Canada – New Paths through COVID-19: This project will provide an in-depth look at the wide range of services provided by New Path Child and Youth Services in Simcoe County, Ontario and how it transitioned all of its services except for residential, to telephone and virtual delivery.

Wood’s Homes – An Assessment of the Implementation, Provision and Impact of Virtual Services: Prior to the COVID-19 pandemic, virtual service delivery supplemented the vast majority of in-person services provided by Wood’s Homes youth mental health programs. Virtual technology became the primary method of service H delivery as of March 20, 2020. n

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NOVEMBER 2020 HOSPITAL NEWS 7

NEWS

Physician helps build model to project local COVID-19 numbers

By Ana Gajic nfectious disease physician Dr. Sharmistha Mishra experienced the early days of the COVID-19 pandemic as a flashback. Everywhere she looked were echoes of Ebola and her work in Sierra Leone.

She saw the crucial role nurses play as the main connecters to the patients.

She saw the fear, heightened this time because the disease was at our doorstep. She saw a grounding principle of her practice come to life once again: we will always know more tomorrow than we do today.

“As Infectious Disease practitioners, we live in the world of uncertainty,” says Dr. Mishra, a physician at St. Michael’s Hospital, a scientist at MAP Centre for Urban Health Solutions and a mathematical modeler. “That’s part of our training, and that’s so much of what an epidemic is. We can transfer knowledge from other epidemics but there is always an adaptive nature to our approach.”

To prepare for that uncertainty, hospital leadership approached Dr. Mishra in February with a question she, as a mathematical modeler and infectious disease specialist, was uniquely suited to tackle: Can we project how the pandemic will unfold in Unity Health Toronto’s two acute care sites, St. Joseph’s Health centre and St. Michael’s Hospital?

In the end, the work by Dr. Mishra and her team, published in CMAJ Open, would be described by leaders as an ‘eerily accurate’ depiction of how the surge unfolded at the two sites.

Though mathematical models were common in the beginning of the pandemic – and still are – they were made with a provincial, national or global lens. None, before Dr. Mishra’s, was tailor made to Unity Health Toronto to help with a local response.

“Our leadership wanted to be as data-driven as we could about this and that’s what they want going forward,”

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Dr. Sharmistha Mishra worked in Sierra Leone during Ebola and helped build a model to project local COVID-19 numbers.

WE NOW KNOW SOME MORE OF THE NUANCES THAT AFFECT COVID-19 RISK, LIKE CONGREGATE SETTINGS, AGE GROUPS, AND SOCIAL DETERMINANTS OF HEALTH.

she says. “We want science to drive our response, and that’s what we did in the first wave.”

The project started with the team trying to determine the simplest model that would capture how this disease could spread. This would help them predict how many COVID patients would potentially be admitted, and how many would have severe enough symptoms to be in intensive care.

Her team then set out to find data that could inform the model and project the answer to their initial question.

They pulled existing studies, historical data on pandemics, the hospitals’ data on admissions and bed capacity, and health administrative from ICES to understand what the catchment areas of the two sites looked like.

The biology of COVID-19 and how long the virus could be passed on also

informed their modelling. They estimated its severity rate and the percentage of people that needed to be hospitalized. The Decision Support team, and Infection Prevention and Control helped the scientists pull numbers and ensure the model made sense for the network.

“The data was changing day by day,” Dr. Mishra recalls. The first iteration of their model was built in four days. Then the team took another three weeks to nail down the science and offer more robust scenarios for the hospital to plan its approach.

The most reliable projections in mathematical models are those based on the most recent data. The projections the team made based on the prior two or three weeks would fit the next two or three weeks, and so on.

“A key lesson in this exercise was that we had to constantly recalibrate because so many things were changing,” Dr. Mishra says. “If we had used only early data, our projections would have been very different.”

The modelling helped the hospital respond quickly and plan patient flow accordingly. Dr. Mishra said there’s always ways for modelling to improve, and she feels ready to have an even better approach for a second wave of the disease.

“We now know some more of the nuances that affect COVID-19 risk, like congregate settings, age groups, and social determinants of health. I feel like we’re in a much better place now to be more adaptive in our modelling as well as our response.”

Dr. Mishra also hopes her team’s work can be used by other hospitals to project their own numbers. Everything they’ve created is open source and generalizable.

“That’s another similarity from my work in Ebola that I’ve seen with COVID-19: everything has become less about the individual and more H about the collective.” n

Ana Gajic is a senior communications adviser at Unity Health Toronto 8 HOSPITAL NEWS NOVEMBER 2020

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NEWS

New Mental Health Strategy for children develops new pathways to care hat one in five children have a mental health disorder is a hard stat to hear.

That only one in six of those children are able to access the mental health care they need is even harder to accept.

SickKids’ comprehensive Mental Health Strategy – the first of its kind encompassing the entire SickKids mental health enterprise – sets the stage to develop new pathways to care for children, youth and families to access the mental health services they need more quickly and more efficiently than ever before. Likewise, the strategy empowers SickKids staff to provide a more seamless child and family experience – a strategic direction of the SickKids 2025 Strategic Plan.

“For more than a decade there has been a ‘great awakening’ with respect

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Building a strategy for child and youth mental health, from left: Christina Bartha, Dr. Peter Szatmari and Neill Carson to child and youth mental health,” says Christina Bartha, Executive Director, Brain and Mental Health Program at The Hospital for Sick Children (SickKids) and Executive Director, SickKids Centre for Community Mental Health (CCMH). “This is one of the best early intervention and preven-

tion strategies you can invest in. The downstream benefits of this are enormous – and essential.”

Bartha, who is also co-Chair of the Mental Health Strategy Steering Committee at SickKids, says the strategy is big and complex, but points to three elements she considers

crucial in the five-year plan’s success: • Supporting SickKids staff. Clinical staff are well-trained in the delivery of physical medical services, but some may not have had enough support in developing their skills around the management of distress and mental health. At the only paediatric ICU in the Greater Toronto Area, SickKids staff may be faced with tough situations related to mental health crisis and SickKids believes it can do more to support them in acquiring the right competencies.

• Engaging stakeholders. Consultations included 21 community organizations, 56 patients and families, 23 focus groups and more than 350 SickKids staff. Indeed, the principle of co-design is embedded in the strategy, which means having stake-

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NEWS

CLINICAL SERVICES AND RESEARCH ARE DEPENDENT UPON EACH OTHER AND SHOULD ALWAYS BE LEARNING FROM EACH OTHER. THE MENTAL HEALTH STRATEGY IS A FRAMEWORK FOR THAT INTERDEPENDENCE, THAT COLLABORATION, THAT INTEGRATION. holders involved in crafting the plan from day one.

• Committing to integration. The delivery of mental health care and physical health care should not be done in silos or in parallel because these conditions are often related.

That’s why, underlying the strategy, is the overall aim to provide improved and holistic treatment across the SickKids network – hospital, research, education, community.

Even before its integration with SickKids in 2017, SickKids CCMH staff collaborated with SickKids staff to support children and families with complex needs.

“The new SickKids Mental Health Strategy envisions staff, community

partners and families working together to build on years of clinical experience and collaboration to create a more integrated continuum of care between the hospital and the community,” says Neill Carson, Clinical Director and Site Lead at SickKids CCMH. “This strategy will not just improve access.

It will extend our service reach to better meet the needs of our clients and community, giving children, youth and families the right level of care where and when they need it.”

Dr. Peter Szatmari, Chief of the Child and Youth Mental Health Collaborative (SickKids/CAMH/U of T) and Co-Chair of the Mental Health Strategy Steering Committee, sees SickKids in its entirety as a “learning

health system.” He’s particularly excited by the dynamic interplay between clinical services and research that figures prominently in the strategy.

“Clinical services and research are dependent upon each other and should always be learning from each other. The mental health strategy is a framework for that interdependence, that collaboration, that integration,” he says. “We want to build a sufficient critical mass of researchers, with a mental health lens, all working together.”

Bartha acknowledges the strategy was a massive undertaking but one that will lead to a major culture shift that benefits patients, families and staff.

Although it’s a strategy for the long term, a year from now she sees Sick-

Kids being in a better place in terms of trauma-informed care, safety planning and the prevention of escalations and distress in kids and youth who present for care.

“When I think back to the parents, caregivers and youth who communicated such a sense of urgency upon us to move forward on a new mental health strategy, their messages were received loud and clear. I feel really proud of the work that we’ve done, and will do, to bring it to life,” Bartha says. “The strategy empowers us to do a much better job and we’re going to deliver on that for the families, children and youth we serve.”

For more visit: https://2025.sickkids.

H ca/mental-health n

This article was provided by The Hospital for Sick Children.

Today, 11 million Canadians are living with diabetes or prediabetes.

November 14 is World Diabetes Day. This year, Novo Nordisk Canada Inc. would like to extend a special thanks to nurses for the vital role they play in preventing and managing diabetes.

thank you

Visit youtube.com/DiabetesCareCanada for more information.

NEWS

Ensuring a positive patient experience during a pandemic

By Sarah Benn Orava and Kelly K. he COVID-19 Pandemic has presented unprecedented challenges to the healthcare system, not the least of which was patient engagement – a vital element in ensuring a positive patient experience – a top-of-mind priority at West Park Healthcare Centre in any environment – pandemic or not.

The hospital provides specialized rehabilitative and complex care after a life-altering illness or injury such as lung disease, amputation, stroke, and traumatic musculoskeletal injuries. As a result, many of our patients stay with us for weeks, months or longer. Additionally, many patients have a physical disability or communicate with their care team, family and peers using alternate methods. All of these factors helped shape our COVID-19 Patient Engagement Strategy.

Over the course of the pandemic, ranges of Infection Prevention and Control measures have been implemented in hospitals to protect the safety of patients and staff. To reflect our core values, we have placed additional emphasis on our patient experience. Despite the challenges presented by the pandemic, our commitment to patient experience has stood strong.

“From the outset we knew engagement of patients would continue to be an important strategy of our overall pandemic response” noted Kim Cook, Vice President, Programs, Chief Nursing Executive and Incident Commander at West Park Healthcare Centre.

The COVID-19 Patient Engagement Strategy was developed by the Patient Experience Department in consultation with patients and families. The strategy was built on three pillars – consistent access to information; a reduction in social iso-

CONNECTION WITH LOVED ONES

T

Sarah Benn Orava and Kelly K. lation; and continuous connection with loved ones.

ACCESS TO INFORMATION

Timely and clear communication has been integral throughout the duration of the pandemic. Patients and their families continue to be kept informed on the ever-changing status and response to COVID-19. Information includes how the hospital is responding, how many active cases of COVID-19 are being reported at the Centre; the impact on patient care; and emotional and mental health information such as coping strategies, techniques, resources and regularly scheduled support groups. Reliable communication to all patients and family members takes place through various media including unit specific forums to engage patient and families, website and social media

updates, an email distribution list, hard copy updates, and Patient and Family Town Halls with an opportunity to ask questions directly to senior leadership.

REDUCING SOCIAL ISOLATION

The pandemic has been and continues to be an isolating time for everyone, but especially for patients and their families at West Park. To help minimize the feelings of isolation that intensified with necessary visitor restrictions, West Park created a larger team using redeployed employees to conduct daily friendly visits with patients. In addition, West Park modified recreation therapy, to provide leisure activities and reduce stress during the uncertain times. Taking this one step further, volunteers who were unable to come to West Park were engaged virtually to share their time with patients.

Regular communication and ongoing connection with patients’ loved ones has been essential. West Park has been achieving this through virtual communication made possible by staff facilitation when required. As well, additional communication devices were secured to support various communication needs.

This approach was featured in the Patient Experience Journal Special Issue: Sustaining a Focus on Human Experience in the Face of COVID-19 entitled Maintaining a positive patient experience during COVID-19 in a rehabilitation and complex care setting.

“We felt it was important to share the work we undertook in partnership with patients and family members as we head into a second wave of COVID-19,” says Cook. “We also hope to learn from others as we face another wave of COVID-19 this fall and winter.”

LOOKING AHEAD

Moving forward, there is still work to be done, as West Park embarks on restoring clinical services and enters a “new normal” with COVID-19. Now, more than ever, the human experience is an integral foundation, and we are hopeful that the efforts West Park has made to acknowledge each person have helped build this foundation.

We will continue to strive to listen, to work with dignity, to communicate in diverse ways that are clear and understandable, and to demonstrate how we stand together to overcome the challenges presented by COVID-19. West Park will continue to be a leader in patient experience and engagement in the Rehabilitation and Complex Continuing Care sector. n H

Sarah Benn Orava, Patient Experience Advisor and Kelly K. is the Patient Family Advisor and Patient Family Advisor Co – Chair.

12 HOSPITAL NEWS NOVEMBER 2020

www.hospitalnews.com

New research shows

NEWS

minimally invasive heart procedure for aortic stenosis delivers cost savings over time

By Melicent Lavers-Sailly common perception that minimally invasive surgery to repair aortic stenosis is more expensive for hospitals than open heart surgery may be painting an incomplete and inaccurate picture, says a recently released Canadian research paper.

The study, Breaking Down the Silos: Transcatheter Aortic Valve Implant Versus Open Heart Surgery, conducted a budget impact analysis of therapeutic alternatives for the treatment of high-risk severe symptomatic aortic stenosis patients comparing minimally invasive Transcatheter Aortic Valve Implant (TAVI) to Surgical Aortic Valve Replacement (SAVR).

It found the overall cost of a hospital treating an aortic stenosis patient over the course of a fiscal year is marginally less when they receive TAVI because patients are generally required to spend less time in hospital and experience fewer adverse events – like life-threatening bleeding, atrial fibrillation, stroke and cardiac arrest – with the minimally invasive procedure than when they undergo open heart surgery.

“My findings indicate that TAVI is more expensive up front for the procedure itself, but it becomes slightly less expensive than open heart surgery when you consider the patient’s healthcare a year out,” says study author Hamid Sadri, Director of Health Outcomes, Research and Technology at Medtronic. “Hospitals may benefit more if they look at the cost of therapy over one year rather than the common practice of going procedure by procedure.”

Surgical aortic valve replacement, the conventional treatment for highrisk aortic stenosis, is an open-heart procedure in which the aortic valve is surgically replaced. TAVI is a minimally invasive alternative in which a bio-prosthetic valve is implanted into

A

the patient’s heart via a catheter inserted in their groin.

“While TAVI was initially reserved primarily for extreme-risk patients when it was first introduced a decade ago, its use has gradually been extended to patients in lower risk categories (high-risk) at many hospitals,” adds Caroline Merineau, Senior Clinical Specialist at Medtronic.

Sadri’s research examined the total cost of treating a hypothetical cohort of 100 high-risk patients with aortic stenosis, including the surgical procedure itself and the subsequent management of potential adverse events and follow-up visits over the course of a year.

He determined the average per-patient cost of performing a TAVI procedure ($52,576) is slightly more expensive than SAVR ($48,578). However, the average cost of managing adverse events in the first year after the proce-

dure is more expensive for patients undergoing SAVR ($17,718) than TAVI ($11,754).

As a result, Sadri pegged the total cost of care in the first year for a patient undergoing a TAVI procedure at $64,330, a cost savings of $1,996 compared to SAVR, which had a total cost of $66,296.

While the savings per patient are marginal when you look at them individually, Sadri said his research has broader implications for hospitals when considering overall patient caseloads and optimizing healthcare resources.

Consideration should also be given to patient preference, he said, noting that a number of studies have demonstrated patients would rather opt for minimally invasive procedures that require a shorter hospital stay, when given the choice.

At a time when hospitals are being challenged to ensure they have capaci-

ty to deal with the ongoing COVID-19 pandemic, minimally invasive procedures, such as TAVI, can play an important role in freeing up bed capacity, adds Merineau.

“By itself one procedure may not provide substantial benefit to the hospital or to the healthcare system. But imagine 100 different procedures – if you replicate this format for multiple technologies and multiple procedures, the sum of all the savings, could be very substantial to the system,” Sadri says.

But in order to reap these types of benefits, hospital administrators would have to be willing to re-examine how they traditionally allocate budgets and deliver patient care.

“The system has created these arbitrary silos within hospitals. People tend to look narrowly at their own budgets or the cost to their department, compared to the whole cost to the hospital or the health care system,” Sadri says.

He believes hospitals may be able to realize savings while providing improved experiences for patients and hospital staff at the same time, if they were to allocate budgets based on the total cost of treating patients over the course of a fiscal year, building in the flexibility for professional judgements by clinicians, rather than making per-procedure budget allocations.

“The patient flow should dictate where the money goes, not individual departments or segments in a healthcare system,” he ssays. “If I go to hospital, the hospital ideally should provide me the best procedure available based on clinical judgement and clinical guidelines and provide me as a patient the best experience I can get.”

You can find a full version of Breaking Down the Silos: Transcatheter Aortic Valve Implant Versus Open Heart H Surgery at journals.sagepub.com n

Melicent Lavers-Sailly leads Communications for Medtronic Canada.

14 HOSPITAL NEWS NOVEMBER 2020

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A client’s MVP.

Troy Lehman loves football. When he isn’t working on personal injury cases involving municipal liability and other complex issues, this busy lawyer plays quarterback on the flag football field. Playing quarterback is all about strategizing, getting the ball to your teammates and working to get to the goal line.

As a litigator, Troy knows that careful planning, teamwork and focusing on his clients’ goals is the key to success. Troy is a litigation quarterback, planning the plays and involving the right experts to work in a tight formation. This approach keeps the case moving to the end zone.

There is one other thing you should know about Troy. Whether it is on the football field or in the courtroom, he can’t stand to lose. In football, winning is about who scores the most points. In personal injury law, winning is about exceeding your clients’ expectations. As a personal injury lawyer, Troy wins the game when he obtains compensation for his clients that will help them rebuild their lives in a meaningful way.

To learn more about Troy visit www.oatleyvigmond.com/troy Proud Member

1.888.662.2481 oatleyvigmond.com

FROM THE CEO’S DESK

Together is better

By Dr. Gillian Kernaghan

W

e’re in this together” became a unifying phrase that emerged in the early months of the pandemic – simultaneously a rallying call and a message of encouragement and comfort during a long and often lonely battle.

For hospitals, “together” was considered from the outset as the only way to confront and manage the historic challenges that quickly arose as the pandemic swept in. A regional approach to planning was, and continues to be, at the forefront of the pandemic response for hospitals across the province and in Southwestern Ontario.

Supplies, capacity, staffing, services, ethics and principles – a regional approach during the first wave of the pandemic allowed for variation across Southwestern Ontario but also consistency as the hospitals and other care providers worked together to provide support, expertise and shared resources. The province directed what needed to be done and the regional leads led the response on how it would be done.

But with no blueprint on how to deal with COVID-19, many unknowns, constantly changing information and directions, and a global shortage of per-

“

sonal protective equipment, the task during wave one of COVID-19 was monumental. The need for rapid-fire decisions and frequent course changes made regional planning with multiple sectors essential. It allowed for greater understanding of some of the unique challenges due to geography and greater appreciation of the contributions of all the partners in the system. People came to the table with a spirit of collaboration and cooperation, and a focus on keeping our patients, residents, staff and physicians safe.

As we navigate the second wave of the pandemic, we are on more solid footing and the spirit of collaboration continues. However, the reintroduction of health care services will create a unique set of challenges. As hospitals increase surgeries and home care is needed to support those patients, and as other sectors resume services, the emerging issue in wave two is the availability of appropriate human health resources to address all the needs in the system.

Once again, it will take new approaches and innovative thinking, locally and regionally. It will require us to work together to maximize limited human resources and to minimize the

Dr. Gillian Kernaghan impact on the people we serve in our communities and regions.

During the first wave of the pandemic, the many lessons learned are an invaluable spin-off of this unprecedented time. All position our region well, not only for this next wave of COVID-19, but also for the advancement of the province’s new integrated model of health care and Ontario Health Teams.

We learned we can lead in uncertainty and implement with innovation and speed when required. We learned the system is better when sectors work

together with a common goal and purpose. We learned that crisis brings out the best and the worst in people – and we should not be surprised by that. We learned that shutting out visitors and family caregivers has a great impact on the health of people, especially those in long-term care or palliative care.

Most importantly, and with great pride, we affirmed that the greatest strength of the health care system is the people who work in the system – in every role and discipline. It is their resiliency and dedication that continues H to see us through. n

Dr. Gillian Kernaghan is President and CEO, St. Joseph’s Health Care London, South West Regional Pandemic Lead.

Perspectives on what culturally appropriate care means

By Zahra Akbar

anadians often pride themselves on their universal and accessible health care system. Only recently are we becoming truly understanding and conscious of the many populations of people who are often excluded. In the 2019 annual report on the state of public health in Canada, Dr. Theresa Tam, the Chief Public Health Officer, identifies the inequalities that affect many people in this country.

C

Inclusive health care services for marginalized and stigmatized populations is top of mind for many in the health care space. Community members, practitioners, and funders often find themselves asking how to ensure health care services are inclusive of the populations they serve.

CADTH – the Canadian Agency for Drugs and Technologies in Health – recently undertook a rapid qualitative review to investigate how people

engaged with health care services that are situated within Indigenous communities, or largely oriented toward Indigenous peoples, understand inclusive care. This review is intended to help inform practitioners or funders who are working toward making health care services more inclusive. CADTH is an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures.

CADTH reviewed qualitative evidence from multiple sources. Then, they appraised and summarized the information that provided insight into the expectations, experiences, understandings, social relations, and perspectives of people engaged with health care services oriented toward Indigenous peoples. The majority of the studies included in this review were conducted in Australia and Canada (which, we acknowledge, are the Continued on page 17

16 HOSPITAL NEWS NOVEMBER 2020

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EVIDENCE MATTERS Continued from page 16

Culturally appropriate care names given to these regions by settlers, not by the peoples indigenous to these lands).

First and foremost, the report notes that building inclusive health care services can not be led by settler service providers alone. Rather, it requires ongoing and conscious participation, direction, and oversight from the Indigenous peoples who live in the locations where these services will be provided. To address exclusion, those involved in planning and providing health care services must consider where Indigenous perspectives are being left out. It is not easy. The process involves ongoing reflection from leaders and practitioners on how individual behaviours, or institutional or systemic practices, result in and reinforce exclusion.

In the CADTH review, exclusion is defined as “that which marginalizes and places on the periphery – it denor-

malizes.” The review hones in on the way the absence, or limited presence, of Indigenous interpreters in health care settings results from more than a simple lack of resources. Rather, the absence is pulled from deeply racialized notions of Indigenous peoples’ ability to understand and fully engage with the health care system in the first place because they don’t “think like us.”

To address these exclusionary practices, it is important that health care providers, and others working within the health care realm, remain aware of and critique their own cultural norms and practices. In order to attempt culturally appropriate care, individuals working with Indigenous peoples need to be aware of stereotypes and stigmatization, and they should be careful not to assume to know what an Indigenous person wants. A salient point from the CADTH review is that individuals can be trained to identify the interpersonal

practices of exclusion in their own lives so that they can recognize when their own values or mindsets are being given privilege.

One example in the review draws from an event where an Indigenous person was labelled as aggressive by hospital staff. The question asked was whether the individual had actually acted aggressively toward staff or whether the label was based off of a stereotype of Indigenous peoples in hospital settings. Was it not possible that the Indigenous person was simply expressing distress over the reason they needed to be in the hospital and that their expression of distress was seen as unacceptable? Exclusion is fundamentally about the lack of belonging and being seen as outside the acceptable norm – recognizing one’s complicity with practices of exclusion involves reframing the stakes of the encounter.

The most notable and practical finding from the CADTH review is that inclusive health care services need ongoing and continuous consideration of external factors that are specific and relevant to the health care service area. To accomplish this, all the individuals involved need to reframe the concept of inclusion from “how can we bring or include Indigenous peoples into our care services” to “how can we participate and include our practice into the lived realities of the communities we are situated within.”

To view CADTH’s full report, go to cadth.ca/building-inclusive-health-care-services-rapid-qualitative-review. If you would like to learn more about CADTH, visit cadth. ca, follow us on Twitter @CADTH_ ACMTS, or speak to our Liaison Officer in your region: cadth.ca/liaisonH officers. n

Zahra Akbar is a Knowledge Mobilization Officer at CADTH.

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NOVEMBER 2020 HOSPITAL NEWS 17

MEDTECH 2020

Seventh annual

MedTech supplement A

s the association that represents the medical technology industry in Canada, the health and well-being of Canadians is of the utmost importance to Medtech Canada. Our member companies have been working around the clock to ramp up production, develop new innovative solutions and collaborate with our government and health system partners to fight the pandemic and help provide our country’s healthcare heroes on the front-lines with the technologies and supplies they need to save lives.

Whether it be diagnostic tests that enable the diagnosis of disease, personal protective equipment (PPE) for front-line health care workers or respiratory support equipment that

aids in the healing of the sick, medtech companies in a variety of different product areas have taken significant actions to play a role in fighting COVID-19.

Around one quarter of our members surveyed retooled their manufacturing facility or collaborated with another company to produce COVID-19 products and 43 per cent introduced products that help ease the burden on hospitals right now. In this supplement, we highlight Medtech Canada’s COVID-19 Action Hub, a website we created that showcases specific examples of companies providing innovations and collaborating with the Canadian healthcare system.

We’ve also advocated with governments throughout the pandemic to

ensure that our industry was deemed an essential service to ensure that our members could continue to support their healthcare partners.

Healthcare systems across Canada had challenges ensuring that their supplies of critical products were able to meet the demands even before the pandemic. Now having been through the initial pressures of COVID-19, we know that the federal government and provincial governments need to have larger inventory buffers to meet peak demand – this is something we’ve engaged with government officials about at both the provincial and federal level. The good news is our governments are working with companies to ensure some manufacturing of key products in done in Canada – as exemplified

by the recent announcement that 3M will soon be manufacturing N95 respirators in Canada.

While there was much focus on COVID-19 related products and solutions, our association also continued work in our core areas of focus including: promoting strategic supply chain and funding reforms, maximizing of digital/connected health technology solutions, and engaging patients and clinicians on advocating for access to medical interventions. Many of the existing issues in these areas were put into sharper focus by the pandemic and it’s provided examples of governments, healthcare and industry working together to rapidly adopt innovations, such as we’ve seen with a variety of digital health solutions.

goes direct in CANADA! Sebia is pleased to announce the opening of Sebia Canada, starting July 1st 2021.

We will be delighted to interact and serve you directly to offer you our diagnostic solutions for medical laboratories.

Our Sebia local team is very excited to engage with you.

To contact us, send an email to canada@sebia.com.

We, at Sebia, care about customers’ satisfaction.

MEDTECH 2020

Our association has also been engaging with governments and healthcare stakeholders on the increasingly critical issue of addressing procedural and surgical backlogs across the country. Many jurisdictions across Canada struggled with significant wait times before March and these have been greatly exacerbated by the pandemic.

We’ve undertaken a number of measures on this front, including: • Advocating for governments to address the backlog in deferred services as quickly as possible with incremental funding to expand capacity and investments in high-value medical interventions to reserve hospital resources, while acknowledging the significant challenge with human resource burnout.

• Requesting that governments provide opportunities for the medtech industry to offer solutions to address the surgical backlog issue (the Quebec Ministry of Health recently put out one such call for solutions).

• Provide procedural data by hospital so that companies can meet both the immediate and future customer demand for essential products. COVID has significantly disrupted what would be traditional inventory ordering patterns used for business forecasting.

We look forward to continuing to engage with governments and healthcare stakeholders across the country on these very important issues.

It’s a privilege for our industry to be able support the Canadian healthcare system and on behalf of our associa-

tion I’d like thank the healthcare heroes across Canada that are providing excellent care during these challenging H times. n

Brian Lewis President and CEO, Medtech Canada

Go to the patient with FDR Xair to reduce the need for patient moves.

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FUJIFILM is introducing a brand new portable X-ray device to contribute to better quality of care in this challenging time.

With its compactness, it enables x-ray exams even in a narrow space where conventional mobile x-rays machines won’t fit such as; ICU, OR, ER, Isolation ward, Care home, Patient home etc*.

Learn more by visiting https://www.fujifilm.ca/products/medical/digital-x-ray/mobile-dr-systems/fdr-xair/ To Contact FUJIFILM Canada: fcan-medical@fujifilm.com *please confirm local regulations for usage environment

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FDR D-EVO II C35 (14 x 17-inch model)

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©2020 FUJIFILM Canada Inc. and its affiliates. All rights reserved.

FUJIFILM Value from Innovation is a trademark of FUJIFILM Corporation

NOVEMBER 2020 HOSPITAL NEWS 19

TOGETHER IN THE FIGHT AGAINST COVID-19

Thank you to all healthcare and laboratory professionals for your passion and courage The power of knowing with diagnostics testing Laboratories, the personnel within them and the diagnostic tests they perform contribute to the majority of the decisions made by the medical community. These unprecedented times have shown us just how valuable and important they are; not only now while our healthcare system relies so strongly on labs and the diagnostic tests they provide, but at all times.

We salute the extraordinary efforts made on behalf of all the heroes who stand on the front line of the crisis as well as those making a difference from the sidelines. We are honored to fight COVID-19 alongside you and rest assured that you can count on us.

Our purpose: “Doing now what patients need next” From our Canadian head office based in Laval, Quebec, we offer a unique array of diagnostic tests, IT solutions and instruments to hospitals, laboratories, healthcare professionals, doctors, researchers and patients all over Canada.

Our portfolio offers solutions spanning across diabetes, infectious diseases, cardiology, oncology, women’s health and many other health conditions.

The value of point-of-care testing and digital solutions The COVID-19 pandemic brings big challenges that require strong leadership and innovative ideas. We believe that in addition to testing and treatment for COVID-19, a special place for point-of-care and digital solutions can help institutions and health systems gain efficiency and better support patient care.

For more information: rochecanada.com / roche.com / healthcaretransformers.com

MEDTECH 2020 SPONSORED CONTENT

Decentralized point-of-care diagnostic testing: a must to ensure therapeutic continuity with anticoagulated patients in times of COVID-19

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emoving barriers for Canadian patients so that they can better access diagnostic tests has recently taken on heightened importance, especially in the midst of the COVID-19 pandemic.

Proper diagnosis is the only way to ensure that the right choice of treatment regimen is made in a timely manner, but how can we do this more effectively? Point-of-care testing is emerging as a reliable method to improve health outcomes by bringing diagnostic testing closer to the patient across the clinical spectrum, significantly accelerating diagnosis while increasing cost effectiveness. The availability of quick and accurate medical information through point-of-care testing has never been more crucial.

With COVID-19 putting extreme pressures on our healthcare system, there has been a marked increase in point-of-care diagnostic solutions combined with telehealth. The increase can be attributed to attempts to minimize potential virus exposure by taking patients out of the institutional setting, thereby safeguarding their health and that of healthcare providers. When doing so, however, an important balance needs to be struck to maintain therapeutic continuity for patients, especially for those with conditions that require ongoing medical counselling to manage health risks and adjustments to dosages.

LIFE CHANGER

Patients on anticoagulation treatment are a case in point. They account for one percent of the Canadian population (i.e. more than 350,000 Canadians), mostly 55 and over, which is a group already at increased COVID-19 risk. Despite the introduction of new oral anticoagulants, warfarin continues to be the standard of care in the prevention and treatment of thromboembolism. With some 100,000 Canadians currently being treated with warfarin and requiring regular diagnostic testing to evaluate proper dosage, they are

Although there is currently no provincial coverage for CoaguChek® test strips outside Quebec, clinicians and healthcare administrators have an important role to play in sharing the benefits of the CoaguChek® system and INR point-of-care (meter) testing with provincial government representatives and other healthcare professionals.

Increased awareness among healthcare decision makers would go a long way in making INR point-of-care testing meters more accessible across the health system.

(inset) INR testing anywhere and anytime with immediate results. (main) CoaguChek® enables patients to participate actively in their treatment without having to visit a hospital or clinic. Thanks to INR testing with immediate results. well-served with a small portable reading device to self-monitor coagulation from the comfort of their own home, such as the CoaguChek® coagulometer.

BOB’S STORY

Bob Ramsay is one such patient.

After an aortic valve replacement, Bob was placed on life-long anticoagulant therapy, which required him to undergo INR (International Normalized Ratio) testing at a Toronto-based clinic twice a week. When he heard about self-testing, he was immediately interested.

CoaguChek® enables patients like Bob to take charge of monitoring their blood coagulation themselves and to participate actively in their treatment without having to visit a hospital or clinic. All is needed is to take a drop of blood from a fingertip – a virtually painless step - and insert the test strip into the device for analysis. In just one minute, the system reveals the coagulation result with an accuracy very comparable to that of a laboratory test.

This is in direct contrast to the impact of testing in a clinical setting, which contributes to absenteeism at work, challenges for people with reduced mobility, as well as other difficulties that threaten treatment adherence.

BETTER OUTCOMES AND LOWER RISK OF COMPLICATIONS These frequent visits also monopolize important health system resources, requiring the work of nurses, laboratory technicians and physicians for each analysis, in addition to increasing the risk of exposure of more vulnerable patients to contagious viruses in the hospital environment.

DECREASING THE BURDEN ON THE HEALTHCARE SYSTEM

CoaguChek® offers reliable support for follow-ups by clinicians, providing patients with peace of mind while decreasing the burden on clinics and hospitals. Manufactured and distributed in Canada by Roche Diagnostics for the past fifteen years, CoaguChek® is an easy-to-use and effective fingerstick technology that helps patients measure their own IRN from a single drop of blood. Each test takes no more than one minute, providing nearly immediate results and adjustment in medication with minimal patient discomfort, all in the comfort of their home. They are also able to interact remotely on a regular basis with their physician – or even their pharmacist – to share results and discuss dose-adjustment guidelines.

Dr. Samer Makhaly, a resident physician and Hematology research co investigator at McGill University, provides additional insight on the benefits of CoaguChek®.

“I have worked closely with many patients using the CoaguChek® device. With proper training, patients find the device user-friendly, convenient and time saving,” he explains.

“With the help of ‘point-of-care’ technology, patients feel empowered and are actively involved in their own care.

This has reflected positively on multiple aspects, including patients’ compliance, as well as the time in which they are in their target INR range.”

Numerous studies have shown that patients who frequently measure their INR themselves have better treatment outcomes and a lower risk of complications 1, 2. “In addition, the combination of warfarin and self-monitoring is a cost-effective solution for stroke prevention and offers equal or better efficacy than the new class of oral anticoagulants. Broader adoption of POC INR monitoring tools can provide high quality anticoagulation management, address the burden of increased costs associated with anticoagulation therapy and help institutions gain efficiency during the challenging time of the pandemic. ■ H

Learn more on a novel model of care in anticoagulation management: podcast and article http://sagepublic.sage-publications.libsynpro.com/hmfroche-diagnostics-division-of-hoffmann-la-roche-limited-podcast-a-novel-model-of-care-in-anticoagulation-management.

For more information: https://coaguchek.ca/en & rochecanada.com 1. Garcia-Alamino JM, “Self monitoring and self management of OAT,” Cochrane Review 2010.

2. CADTH, “Guidance on the usage of POC,” CADTH Report 2014, Volume 3, Issue 1C

www.hospitalnews.com

NOVEMBER 2020 HOSPITAL NEWS 21

MEDTECH 2020

Canada lags in

innovation adoption Assessment of select technologies reveals that some Canadian technologies have better success abroad

By Timothy Wilson anadians are right to be proud of their healthcare system, but one area where challenges exist – and where some practical changes could bring about big improvement – is in the adoption of innovative medical technologies. Too often, Canadians have limited access to health technologies that are widely adopted in other countries.

These technologies are varied. They might be orthopedic devices, technologies that support cardiovascular health, disease-specific remedies, or unique innovations that address chronic pain.

And the organizational profiles are equally diverse. It doesn’t matter if you’re a small, innovative Canadian company, or a large multinational, the truth is that the Canadian healthcare system – despite its many strengths – is not built to embrace innovation.

Intellijoint Surgical is a good example. The Kitchener, Ontario headquartered company’s flagship surgical application, Intellijoint HIP, was the result of a final year design project at the University of Waterloo. The technology, which helps make hip replacement surgeries more accurate, has been a great success, with the company having since added a new technology to its roster, Intellijoint KNEE. Intellijoint Surgical has been on a winning streak, selling its products into global markets, and reinvesting in innovation here in Canada – despite the fact that Canadian sales are not the company’s major growth driver.

The numbers tell the tale. For Intellijoint Surgical’s two products, the United

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States represents 71 per cent of sales, and Australia 26 per cent of sales. Canada represents a modest three per cent of sales. This, despite the fact that Intelli-

22 HOSPITAL NEWS NOVEMBER 2020

joint Surgical launched it’s first product in Canada in August 2015, and entered the US market in February, 2016, and the Australian market in November, 2016.

It might be tempting to dismiss these numbers. After all, it’s just one example. There could be circumstances unique to Intellijoint Surgical that help explain the situation. However, an examination of a second Canadian medical device company, in a similar market, tells a similar tale.

Synergy Disc Replacement is another remarkable Canadian success story. The Cambridge, Ontario headquartered company was founded in 2005 by a Canadian neurosurgeon. It has developed a revolutionary artificial cervical disc replacement technology, and possesses over 55 world-wide patents.

One would expect that such an impressive company would have been embraced here at home. However, Canada, represents less than one per cent (0.6) of Synergy Disc’s global sales. On a per-unit basis, the United Kingdom accounts for 25 per cent of sales and Germany represents 36 per cent. Australia, which has a population of 25 million – smaller than Canada’s 38 million – is Synergy Disc’s largest market, at 37 per cent Upon entering the US market, which represents about 60 per cent of the global disc replacement market, Synergy Disc Replacement will likely see a dramatic change in those figures.

These are Canadian companies – their technologies were conceived of and built, with Canadian know-how,

yet Canadians are not receiving the full benefit of the innovation.

Why? The problem is easy to describe, and hard to fix. Canada has a supply side market. We establish budgets, and then fill those silos. The market isn’t built to respond to demand. It has difficulty pulling innovation into it. The system is unlikely to purchase products that deliver value over time, because the incentives are to acquire volume at lower price points. The result, then, is to purchase cheaper, commodified products, in order to stay under budget, and not to rock the boat.

This reality is faced by everyone. It doesn’t discriminate between smaller, innovative Canadian companies, and bigger multinationals. One good example is DaTscan, a radiopharmaceutical diagnostic agent to help physicians evaluate patients with a suspected parkinsonian syndrome (PS), such as Parkinson’s disease (PD), that was developed by GE Healthcare, and that helps visualize dopamine transporter levels in the brain. It’s of particular value in hard-to-diagnose cases. DaTscan is widely utilized around the world, and received European Marketing Authorization in July 2000, and approval by the Federal Drug Administration (FDA) in 2011. The technology was approved in Canada late in 2017. Since then, it has had virtually no uptake.

It is true that Canada represents a small portion of the global market; nonetheless, the data to date has been discouraging. DaTscan adoption in individual European markets, as well as in Japan, is in the many thousands of doses per country, whereas in Canada, as of the third quarter of 2020, there were only 130 doses.

Continued on page 24 www.hospitalnews.com

ADVANCING CARE IN A NEW LANDSCAPE

Medtronic employees around the world are working together to help health systems navigate the radically altered pandemic landscape by offering shared solutions, resources, and hope.

We’re optimizing the use of our virtual care and remote monitoring solutions to help improve patient and staff safety.

Our minimally invasive surgical technologies are helping patients recover and return home more quickly.

And we’re partnering with hospitals to help improve capacity and patient access within today’s resource constraints, while also helping redesign care delivery systems and processes for tomorrow’s challenges.

LET’S FIND SOLUTIONS — TOGETHER. medtronic.ca

MEDTECH 2020

Medtech Canada

COVID-19 Action Hub ince the start of this pandemic, the medical technology (medtech) industry has made significant contributions to the battle against COVID-19 in Canada, stepping up for Canadians in the fight against this global pandemic.

Medtech companies have drastically ramped up production, retooled their product lines and creatively utilized their devices to help both patients and those on the front lines. Additionally, there has been swift collaboration between governments, providers and medical technology companies in Canada to address the pressing needs

S

of our health care system in light of COVID-19.

The sector has also made valuable contributions helping Canadians access much needed health care services – enabled by innovative digital health technologies – as a result of limited access to our health care system due to the pandemic.

Medtech Canada has been collecting these collaborative efforts and positive stories and we’re pleased to share them with Canadians at the “Medtech Canada COVID-19 Action Hub” website. This article highlights just a few examples from the Hub.

ENSURING CANADA’S SUPPLY OF PERSONAL PROTECTIVE EQUIPMENT

Medtech Canada and our members have been working closely with Public Services and Procurement Canada, as well as provincial government agencies, to ensure that our country has ample supplies of personal protective equipment (PPE) to keep health care workers safe while providing care. A number of companies have undertaken significant measures on this front, including: • Southmedic is a Barrie, Ontario-based medical device manufac-

Continued from page 22

Innovation adoption This, despite the fact that DaTscan is an affordable, easy-to-use, consumable product. According to a 2018 paper in the Journal of Parkinson’s Disease, neurologists in Canada diagnose more than 25 Canadians with Parkinson’s disease each day. By 2031 that number is expected to rise to more than 50 people a day. That’s an annual jump from over 9,125 cases in 2018, to more than 18,250 by 2031.

Recent data from the United Kingdom indicates a misdiagnosis rates as high as 26 per cent. In Canada, it is estimated that 10-20 per cent of diagnoses are uncertain, meaning that, by 2031, 1,825 to 3,650 Canadians could benefit from DaTscan every year.

The challenge with DaTscan is similar to those of the Canadian companies – despite the fact that the products are radically different. DaTscan is perceived as a niche product for a small market. In a supply-side system, if there is limited motivation to establish reimbursements and to update codes, nothing happens. As well, costs are misaligned with demand.

Hospitals and laboratories, which are responsible for budgeting for DaTs-

can, are often in the red and reluctant to do tests that might raise costs, despite clinical demand. For example, DaTscan requires a SPECT scan, and incorporating DaTscan usage into a radiology budget can be challenging.

These various issues play into a larger understanding of Value Based Healthcare (VBH), and the role of Value Based Procurement (VBP), which provides a wider view of the overall benefit of a technology. Ideally, a product should be acquired with an understanding that it delivers the highest value to both the patient and to the system.

However, nowhere is the cost of a missed or late diagnosis of a disease like Parkinson’s (both in terms of treatment, and also with regard to human suffering) accounted for when it comes to paying for DaTscan and similar products. Likewise, if a product raises the cost at the point of surgery, there is limited incentive to acquire it, even if it might improve the patient experience and reduce cost over time.

And though we often speak of money, let’s never forget that in healthcare the job is to minimize human suffering.

What, for example, is the cost of chronic

back pain, both to individuals and to our healthcare system? It’s a heavy burden: pain clinics are often reliant on medications that risk dependency, and surgery is a radical and expensive step that involves specialist referral. However, one promising technology, Spinal Cord Stimulation, has shown remarkable outcomes when addressing chronic back pain.

And the uptake in Canada? Not so good. Industry data on access based on disease incidence indicates that, for Spinal Cord Stimulation, 17 per cent of Canadians with incidence have access, compared to 40 per cent of Australians, 49 per cent of people in Western Europe, and 77 per cent in the United States.

Many other technologies have similar challenges. The answer, given the structure of our healthcare system, is to implement Value-Based Procurement. We already have some success stories. Unfortunately, as is so often the case, they exist in isolation, as pilots, and have yet to result in system-wide change. One day soon, we can hope, we’ll have a healthcare system where funding silos are flattened in order to track the patient journey, and to measure the benefit of innovation. Then, we’ll be able to pull innovation into the system, and to make H the best investment for the patient. n

Timothy Wilson is a research analyst and business/technology journalist with a special interest in healthcare.

24 HOSPITAL NEWS NOVEMBER 2020

turer that distributes to more than 80 countries around the world. The government of Ontario provided the company with $1.8 million to help the company reengineer and retool its current production and purchase new moulding equipment. With this new equipment, the company is doubling its output of oxygen masks, tripling its output of ETCO2 masks, which are specialty masks used to monitor breathing prior to ventilator use, and quadrupling its output of eye and face shields to help meet the province’s need for PPE. • Stryker has the first system approved

by Health Canada to sterilize N95 masks for reuse, allowing front line workers to use one mask up to three times. Hospitals across the country are receiving the Sterizone VP4 technology and will be able to sterilize almost 12 million masks per year, resulting in more than 36 million uses of masks.

DIGITAL HEALTH SOLUTIONS

During the pandemic, digital health tools ranging from virtual consultations to personal health information apps have transformed the delivery of care across Canada. The medtech industry has made valuable contributions in the area of digital health which have enabled patients to self-monitor/ manage chronic disease, supported clinicians in clinical decision making and providing care in a virtual setting.

Some examples include: • m-Health Solutions (mHS) in Hamilton, Ontario has been providing virtual and mobile cardiac diagnostics and monitoring since 2010.

With COVID-19, m-Health Solutions quickly pivoted to meet the needs of doctors/clinics/hospitals and patients. As holter departments in hospitals across Ontario closed, mHS established an on-line portal so that doctors virtually seeing patients from their homes could quickly and securely refer patients and receive reports back.

Continued on page 27 www.hospitalnews.com

MEDTECH 2020

Virtual care helps post-operative

patients heal at home t was 10:30 at night when Ernst Seeger realized he needed immediate medical attention. The Niagara Falls man was at home recovering from bladder cancer surgery and started experiencing intense, escalating abdominal pain.

But instead of going to the hospital emergency department, Seeger, 64, reached out to his virtual healthcare team at Hamilton Health Sciences (HHS) using a tablet computer provided by the hospital as part of a study on virtual care for patients recovering at home after surgery.

“I apologized for contacting them so late but the nurse I spoke to said, `I’m glad you called. That’s what we’re here for.’”

While at the HHS Juravinski Cancer Centre having surgery for bladder cancer in May, Seeger was invited to take part in a national study to test virtual care and remote monitoring technology once he was discharged.

The study – called post-discharge after surgery using virtual care with remote automated monitoring (or PVC-RAM) and administered by the Population Health Research Institute (PHRI) at Hamilton Health Sciences – was launched in response to challenges that hospitals were facing due to COVID-19. When restrictions came into place in early March due to the pandemic, hospitals like HHS began looking for ways to drastically reduce non-emergency care.

Patients were sent home earlier after surgery where possible, and many in-hospital appointments were replaced with virtual visits. These virtual care visits help address serious complications that might otherwise lead to emergency department visits or readmissions.

Investing in research and technology is part of HHS’ vision to transform the way health care is provided, says Dr. Ted Scott, Vice President of

I

Ernst Seeger kept in touch with his health care team post-surgery through virtual care.

Research and Chief Innovation Officer for HHS. “It’s about delivering a more patient-centred and seamless healthcare system and using virtual care and remote technology to allow patients to recover at home and if possible, avoid hospital re-admission,” says Scott.

When COVID-19 struck in early March, the technological revolution was already underway at HHS. The hospital simply shifted its efforts into an even higher gear in response to the pandemic. Hundreds of providers and health care staff pivoted to virtual care models in a matter of days, using phone and videoconferencing to continue providing access to speciality outpatient care for patients.

Since early April, HHS has experienced a 1,000 per cent increase in the use of virtual care with over 93,000 virtual visits between health care professionals and patients. HHS team members have engaged in more than 74,000 phone visits and approximately 19,000 video visits with patients.

In June, PHRI received funding through Roche Canada’s COVID-19

26 HOSPITAL NEWS NOVEMBER 2020

Innovation Challenge and the McMaster COVID-19 Research Fund for PVC-RAM. The trial recruited HHS patients (included in a total of 900 patients from participating hospitals across the country) who had undergone surgery for health issues including cancer, hip fractures and a ruptured abdominal aortic aneurysm.

Patients received interactive remote symptom-monitoring technology, which includes a tablet and equipment to assess their vitals – blood pressure, heart rate, respiratory rate, oxygen saturation, temperature and weight – at home.

HHS nurses run the central command centre in collaboration with perioperative physicians and use a tablet to virtually interact with patients.

Patients can also be connected virtually to physicians. Patients use the remote monitoring technology to record their vital signs at home and information is sent in real-time to the nurses, who escalate care to physicians when medical assessment and intervention are required.

Previous post-operative research has demonstrated that while patients

prefer to recover at home, the highest risk for complications is in the first month after surgery. Data shows that 15 to 20 per cent of post-operative patients will return for emergency treatment or hospitalization.

While patients are safest in the operating room or intensive care unit where they’re closely monitored by technology that will warn of problems and there’s a surgical team that can act quickly if needed, the COVID-19 pandemic has created new challenges for hospitals and care teams. In a quest to keep beds free and people out of the hospital, post-operative patients have been discharged from hospital earlier than would typically be the case. Virtual at-home monitoring technology is playing an instrumental role in helping people leave the OR and ICU sooner and safely recover at home.

Since the project launched in June, the PVC-RAM team has gathered many examples where virtual care helped address serious complications that might have otherwise led to emergency department visits or readmissions.

During his episode, Seeger spoke with a virtual-care nurse through video conferencing and used a tablet to send a photo of his surgical scar which appeared inflamed. The nurse consulted with a physician and Seeger was diagnosed with having an infection and prescribed medication.

“Our staff involved in this study have heard many stories where virtual care has helped address complications that would otherwise have meant a trip to the hospital. We are tracking these instances as part of the study.

Prior to COVID-19, I could confidently say that HHS was in the midst of a technological revolution. But what felt revolutionary just a few weeks ago is beginning to feel remarkably normal.

And for health care and patients, H that’s a very good thing.” n www.hospitalnews.com

MEDTECH 2020 Continued from page 24

COVID-19 Action Hub • Although the stethoscope is an essential tool to diagnose and monitor patients, it brings HCPs within 28 inches of patients, putting them at serious risk of infection, even when using of personal protective equipment (PPE). In response to the COVID-19 pandemic, AusculSciences developed the Auscul-X, a multi-sensor, remote, disposable stethoscope which allows clinicians to monitor patients heart and lung sounds from outside the patient’s room with acoustic fidelity equivalent to an electronic stethoscope.

COLLABORATION TO MEET THE NEEDS OF CANADIAN HEALTHCARE

Since the start of the pandemic, there have been a number of examples of companies quickly collaborating to meet the needs of patients and

the Canadian health care system.

Some examples include: • Roche Diagnostics manufactures a dual swab kit that works with COVID-19 tests. Due to concerns about sterility once the dual swab kit was opened, testing facilities were required to use only one portion of the two-swab kit per person, discarding the unused swab.

Canadian Hospital Specialties (CHS), a medical device manufacturer and distributor in Oakville, had the capacity to repurpose and separate the Roche Diagnostics kits quickly and the two companies worked together in collaboration with Ontario Health to increase the critical swab inventory available in Ontario.

• Ventilators for Canadians (V4C), a consortium of Canadian entrepreneurs, has partnered with Baylis Medical, a Canadian-based medical device company specializing in cardiology and spine, to manufac-

Ontario Premier Doug Ford visited Canadian Hospital Specialties in Oakville to see how they’re increasing the province’s supply of COVID-19 testing swabs. ture ventilators for hospitals across Canada. The Baylis V4C–560 ventilator is based on Medtronic’s Puritan Bennett™ 560 ventilator design, for which the intellectual property was made publicly available by the company. Medtronic has also provided Baylis with engineering support and assisted with

licensing of the Baylis V4C-560 ventilator in Canada.

Please visit the “Medtech Canada COVID-19 Action Hub” to learn more about these and many other examples of the medical technology industry’s contributions in Canada to the fight against COVID-19 at: www.

H medtechinnovation.ca. n

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MEDTECH 2020

Virtual care popularity surges during COVID-19 pandemic

By Season Osborne

H

arrison Brown relies on ParaTranspo to get to The Ottawa Hospital. He used to have to carve a three-hour window for a 15-minute appointment.

But now, he has his doctor’s appointments at home – using his cell phone.

“It’s a game-changer for me,” says Harrison. The 27-year-old from Cornwall has spina bifida and has had to come to the hospital his whole life.

When he moved to Ottawa, either his parents would come from Cornwall to drive him to the hospital or he’d take ParaTranspo. Not having to go to the hospital is “huge.”

The Ottawa Hospital normally has about 37,000 outpatient appointments every month. On March 17, The Ottawa Hospital and other hospitals in the area jointly announced that they

were taking a planned approach to postpone non-urgent surgeries, procedures, outpatient programming and clinics in-line with guidance from the Ontario Ministry of Health.

With that plan now well in place, half of these non-urgent appointments are now being done virtually – right from the patient’s phone, tablet or computer. Not only is this more convenient for patients like Harrison, but it also means fewer patients overall have to come to the hospital during the COVID-19 pandemic.

Harrison’s urologist Dr. Duane Hickling got onboard with virtual care in early 2019. Many of his patients have mobility issues that make coming to the hospital a major event.

“I quickly came to realize most patients would benefit from it,” he says.

“Most people have the technology.

You only need a cell phone.”

28 HOSPITAL NEWS NOVEMBER 2020

In fact, Dr. Hickling now sees 95 per cent of his patients on his computer screen.

“On a typical procedural day, I’d see 25 patients in the clinic; now it’s only one or two,” says Hickling. “Prior to the pandemic, I would estimate I did 25 per cent of consults and follow-ups virtually. Now, almost all visits are done this way. I think that there is a much more widespread uptake of these virtual appointments because the efficiency is very high, and they provide more flexibility.”

“I love it,” says Harrison, as he explained how simple his virtual appointments are.

The hospital staff sets up the appointment, emails a link that he clicks at the appointed time, and then Dr. Hickling comes on the screen. The doctor can look at the test results on his or her screen and the patient can also see them at the same time. Harri-

son says the virtual appointment isn’t much different from an in-person one – only more convenient.

“I’ve done it on my computer and my phone. I’ve even done it on a break at work, which means I don’t have to take time off.”

Harrison is one of the thousands of patients who are now benefiting from years of collaboration between The Ottawa Hospital and The Ontario Telemedicine Network (OTN). OTN is the largest telemedicine network in Ontario and offers two-way videoconferencing access to care for patients.

However, historically, patients still had to go to a health-care centre that was outfitted with specific technology.

Recently, The Ottawa Hospital and OTN partnered to pilot a more advanced virtual care program that allowed patients to use their own devices. The partnership helped the hoswww.hospitalnews.com

MEDTECH 2020

Remote symptom

pital accelerate its virtual care strategy, which focuses on improving the patient experience and improving access to health care.

The Ottawa Hospital further matured its implementation of virtual visits by linking private, secure video conferencing to the hospital’s Epic electronic health information system.

On April 27, the hospital launched the Epic-Zoom video visit option for health-care providers. The Epic-Zoom virtual platform, has also allowed doctors to successfully involve trainees in virtual clinics. Patients can log into their MyChart account using any device equipped with a camera and microphone for a video chat with their provider from wherever they are – home, office, car, or on vacation.

“Virtual care means better access for patients, and more efficient care because patients don’t have to travel, pay for parking, or wait in a clinic room,” says Reece Bearnes, Clinical Director lead for virtual care innovation. “We believe it’s the future of health care delivery.”

Virtual care has become even more popular as a way to provide care during the COVID-19 pandemic.

“Building on the early success of our pilots, COVID-19 quickly accelerated us forward with our virtual care strategy,” says Bearnes, who noted the number of users doubled within two weeks.

“We’re talking about thousands of patients a month now doing appointments virtually.”

Virtual care appointments are ideal for follow ups, providing education, and supporting people with chronic conditions. People still go to the hospital for physical assessments, treatments and procedures, such as blood work or removing stitches.

“Our model of care will be forever positively changed as a result of virtual care innovations, and it is very much here to stay,” says Bearnes. “We will not be returning to the old way of doing things after this pandemic,. Providers are gaining experience, becoming efficient and finding this easy to do. Patients have now come to expect this as an option for their care and are holding us accountable to ensuring we can provide it.”

For Harrison, virtual care means his doctor’s appointment is just a phone call and won’t take up any more time H in his day. n

here are more than 200,000 COVID-19 cases across Canada. When the pandemic hit, the Cardiac Arrhythmia Network of Canada (CANet) took decisive action to adapt its cutting-edge digital health webbased application to address Canadians’ needs.

“The COVID-19 pandemic highlighted the need for effective virtual health care,” says Dr. Anthony Tang, CANet CEO and Scientific Director. “Technology solutions support this care by giving both patients and health care providers fast and accurate access to critical information about symptom progression.”

Co-designed by patients and physicians, VIRTUES (Virtual Integrated Reliable Transformative User-Driven E-health System) is a virtual, patient-centred platform that helps guide COVID-19 positive patients manage their illness.

“VIRTUES provides a way for health care providers to monitor remotely, triage and manage care for patients with COVID-19, and help identify early on those who are at higher risk of complications,” adds Dr. Tang.

This platform delivers a new model of virtual care, supported by Canadian technology that will improve access and delivery of quality care, reduce the stress of patients with COVID-19, decrease exposure to all communities, and protect essential frontline health care workers.

It is a digital solution that ensures the highest security level for Personal Identifiable Information (PII) and medical data abiding by Health Canada’s stringent security standards to protect patient health records and data following the Personal Health Information Protection Act (PHIPA) of Canada.

VIRTUES streamlines the patient assessment process making it faster to

Season Osborne is a freelance writer for The Ottawa Hospital.

Fabian A. Folias works in communications at CANet

www.hospitalnews.com

tracking and monitoring are vital in supporting COVID-19 positive patients

By Fabian A. Folias

T

understand patient needs and identify high-risk patients while limiting faceto-face interaction.

Patients receive an at-home blood oxygen monitor and provided access to the secure web-based application where their data and other vital sign information is input, and their symptoms are logged and tracked.

With VIRTUES, patients will have remote access to a team of health care providers, including those specializing in the fields of cardiology, emergency medicine, internal medicine, infectious disease, neurology, and respirology.

“Using VIRTUES, the care team can monitor a range of symptoms remotely that tells us a lot about how the patient is doing. In addition to tracking their temperature, we are using a home-based pulse oximeter to measure pulse rate and oxygen saturation,” says Dr. Marko Mrkobrada, London Health Sciences Centre physician.

VIRTUES provides alerts for communication between the patient and members of the care team. They can react quickly if additional care is needed, such as visiting the doctor’s office or hospital.

Adapted for COVID-19, VIRTUES is already in use with a CANet-funded study providing remote management to patients who live with either a pacemaker or implantable cardiac defibrillator (ICD). Currently, VIRTUES has been implemented in the COVID-19 Virtual Care at Home research study from the Urgent COVID-19 Care Clinic at the London Health Sciences Centre (LHSC). The virtual clinic helps identify, triage, monitor, and manage potential complications for people recovering from COVID-19 at home.

“We want to learn more about making health care technology user-friendly. Patients will have more information about their care and hopefully will experience reduced anxiety,”

explains Dr. Erin Spicer, London Health Sciences Centre physician.

“While the majority of COVID-19 cases don’t require hospitalization, this system allows us to more closely monitor a patient’s progress and make informed decisions if their symptoms worsen.”

The Ottawa Hospital is also actively recruiting patients with other sites to follow.

“Since enrollment began, we’ve had an influx of patients recruited into the study. Many patients have expressed their satisfaction knowing that they will have remote access to their care team for review and follow up during their recovery,” says Dr. Venkatesh Thiruganasambandamoorthy, Ottawa Hospital emergency physician. “With remote symptom tracking and monitoring through VIRTUES, we want to help alleviate patient anxiety and reduce unnecessary emergency room visits.”

Reducing patient anxiety and improving patient satisfaction are primary aspects that the VIRTUES health care model expects to demonstrate. Other benefits of this digital health solution include reducing health care resources, rapid tracking of case recovery, and early recognition of patients that may require further management, including hospitalization.

This health care model can be adapted further to facilitate other clinical settings and improve the accessibility of quality care to vulnerable populations in isolated, rural, and underprivileged environments.

“We hope to see VIRTUES implemented across Canada. Patients will have access to enhanced care while being able to hopefully stay in their homes during their recovery, helping to decrease the exposure of COVID-19 in the community and for frontline health care workers,” adds Dr. Tang.

To learn more about VIRTUES, H visit www.virtues.care. n

NOVEMBER 2020 HOSPITAL NEWS 29

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

Professional associations:

A community to consider

By Zack Dumont s a member of the executive of the Canadian Society of Hospital Pharmacists (CSHP) I’ve had a crash-course in coming to understand the role and its unique responsibilities.

Being part of several ‘town hall’-like sessions has been a challenging and rewarding experience. Along with the other presidential officers, and our CEO, I’ve gotten out in front of our membership, received positive reinforcement, fielded concerns, answered questions, and we got to ask a few questions of our own. One such question we’ve been asking at these events is “What does CSHP mean to you?”

For me, the answer is easy. CSHP has and always will be my community.

It’s only my professional community, sure, but it’s one that garners a lot of time and attention in my life. Though I celebrate diversity of thought, I was happy to see I wasn’t alone. I was excited to see that many others felt the same, and we’ve got the word clouds to prove it.

I’ve admired this particular community since I was a student over 12 years ago. Over the years, at society meetings and events, I’ve had corny daydreams about how CSHP came to be. I imagine that back in the day (more than 70 years ago!), the leaders in the profession got together and said “hey, I think there’s probably strength in numbers. What if we got together, regularly? What if we did some of the same things at our workplaces when we part? And then, what if we got together again and shared findings?”

That’s probably a massive over-simplification. Yet, I really like the wholesomeness in it. That these folks saw an opportunity to form something – like a co-op – when no one asked them

A

Zack Dumont is President, Canadian Society of Hospital Pharmacists. to or gave them that direction; and certainly, no one else was looking out for them. What compelled them to do that? These leaders just had the vision and, subsequently, the leadership skills to make it happen.

CSHP surges on today. I get the sense that members are feeling the energy, confident that great things are ahead. It remains their society, their co-operative. And I mean ‘their’ entirely. I have the challenge to help

shepherd it over the next few years, but it never stops being theirs. After I’m done, someone else gets a turn. All the while, our meeting place goes on.

Our community never stops, so long as we wish for and will it to carry on.

What ties us together? What is the common thread that makes this feel like home? I suspect as members read or revisit our values (www.CSHP.ca/ about), they’ll likely be nodding their head as they scroll. For me, these values can be summed up as such: the collective privilege to work with patients, where the sole focus is to improve their outcomes. I sleep well at night knowing that whatever medication therapy decisions I make, or I support others to make – to start, stop, or change therapy – it had everything to do with improving patients’ outcomes.

I fit in with the society because I got to see leaders – role models – on display at CSHP, winning awards, publishing in the journal, and because I got to walk amongst them at society events. CSHP, a professional association, is the place to be. It shaped me, it brings me pride, and for that I am so very grateful. My plan is devote these next few years to demonstrating my gratitude, by growing and strengthening our community, one of diversity, inclusion, and focus on improving patient outcomes.

This is only my plan. You do not have to go this same path. Perhaps formal leadership is not for you. However, I do implore you to consider joining and engaging in your professional association. A society, such as CSHP, is indeed greater than the sum of its parts, and as such you will get more from it than you can possibly give. Your professional association: a community H worth considering. n

Zack Dumont is President, Canadian Society of Hospital Pharmacists.

30 HOSPITAL NEWS NOVEMBER 2020

www.hospitalnews.com

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

Adapting cancer treatments during a pandemic

By Snimar Bali uring the first wave of the COVID-19/SARS-CoV2 pandemic, many Canadian hospitals worked towards reducing the frequency of cancer patients needing to come into their facilities. As cancer patients may be immunocompromised and vulnerable to infection, reducing potential COVID-19 exposures in high risk areas like healthcare facilities is in the patient’s best interests. At the same time, hospitals were bracing for capacity constraints due to a potential surge of COVID-19 patients and so were trying to reduce the number of patients being admitted or seen in hospital.

Many hospitals and provincial cancer agencies across Canada focused their efforts on developing potential alternatives for cancer patients to limit their time spent in clinics/hospitals. These strategies always emphasized the importance of devising an individualized plan for each patient in conjunction with a team of healthcare professionals.

Prioritization guidelines were established in the following areas: surgical services, diagnostic imaging, nutrition, pain and symptom management, radiation and systemic therapy, and so forth.

In summary, cancer patients were triaged by their healthcare team into several groups based on their diagnosis, current treatment, treatment intent as well as quality of life. Patients requiring emergency access to care were placed at highest priority, however the health of all patients was supported throughout this time. More details regarding such prioritization plans can be referred to in BC’s Cancer: Provincial Cancer Clinical Management Guidelines in Pandemic Situation (COVID-19).

To manage drugs, supplies, and/or equipment shortages as well as limit interactions within healthcare facilities in Canada, algorithms were created for cancer patients. These algorithms were designed to account for potential adaptions that can be applied to a patient’s current treatment plan. The following are various examples of adaptions that can be made; changing intravenous treatments to oral or subcutaneous alternatives, using regimens with longer intervals, selecting protocols that are

D

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shorter in duration, holding maintenance chemotherapy, delivering medications to patient’s homes, as well as communicating any information regarding the patient’s health electronically via telehealth. Hospital pharmacists continued to work collaboratively with other health care professionals to provide the safest and best clinical care for their patients during this time.

Around the world, the Italian Association of Medical Oncology (AIOM) as well as the American Society of Clinical Oncology (ASCO) have taken a similar approach in adapting can-

cer treatments in the hopes of creating a safe environment for both their patients and healthcare providers. Recommendations that were made by the AIOM include delaying imaging procedures to monitor treatment response, delaying some anticancer treatments, and replacing scheduled visits that are not associated with therapy/administration with email or phone contact, etc. In Canada, Ontario Health has also devised provisional funding measures for cancer drugs to support hospitals as they develop their pandemic strategies. These conditional recom-

mendations were made in case access to therapeutic care became limited.

With this second wave of COVID-19, the prioritization guidelines have now been developed and will be swiftly implemented to support our cancer patients on their journey. As the number of new COVID-19 cases in Canada declines, cancer patients will start to see their management and treatments return towards how they were pre-pandemic. Hospital pharmacists will continue to collaborate with other health care professionals to safely return H patients to their ideal treatment. n

Snimar Bali is a Pharmacy Student at the University of Manitoba’s Rady Faculty of Health Sciences.

Immuno-oncology 101 IMMUNOTHERAPY

In the past decades there has been research to find agents that will remove the cloak or the brake from the cancer cell so that the immune system recognizes it and destroys it. The immune checkpoint inhibitors have been developed and are recognized as another group of agents to fight some cancers. Not all cancers respond to the checkpoint inhibitors. Why this happens is under extensive research.

The response to immune-oncology therapy may be sustained or may be short lived. Again, how or why the tumor stops responding is under active research. It may be that the tumor uses several different pathways to inactivate the immune system.

Immune checkpoint inhibitors used to fight cancer act on different pathways to direct the immune system in destroying the cancer cells. They may promote the activation of the immune system or the may unmask the caner cell. The result is that the tumor stops growing or may be destroyed.

The immune checkpoint agents currently available block the PD-1/PDL-1 (programmed death receptor or ligand) or CTLA-4 (cytotoxic T-lymphocyte-associated protein 4). The PD-1/ PDL-1 inhibitors available in Canada are pembrolizumab (Keytruda®), nivolumab (Opdivo®), durvalumab (Imfinzi®), atezolizumab (Tecentriq®), avelumab (Bavencio®), and

cemiplimab (Libtayo®). The antagonist of CTLA-4 available is ipilimumab (Yervoy®). These may be referred to as monoclonal antibodies or targeted therapy. However, not all monoclonals or targeted agents are immunotherapies.

The checkpoint inhibitors used to treat cancers are given intravenously every 2, 3 or 4 weeks, depending on the agent.

Cancers most likely to respond to immune therapy are lung cancer, skin cancers, throat cancers, kidney cancers and not all agents are indicated in all cancers. Their mechanisms of action may be similar but studies have only been done in specific cancers.

DRUG INTERACTIONS, DOSAGE ADJUSTMENTS

These agents are neither metabolized in the liver nor eliminated via the kidney; they are destroyed in the body and have a relatively long half-life, in the vicinity of 20 days. There is no need for dosage adjustments for patients with renal or liver dysfunction. Drugs that affect liver or kidney function would not interact with these agents.

The drugs that are usually not permitted while on immune checkpoint inhibitors are high doses of steroids as these would lessen or negate the effect on the immune system.

ADVERSE EFFECTS/TOXICITY

Because these agents act to stim-

ulate your own immune system to attack the cancer, the side-effect profile is different from traditional chemotherapy or cytotoxic agents.

Traditional chemotherapy attacks all cells, heathy or cancerous. Nausea and vomiting, or hair loss which are common side-effects of traditional chemotherapy occurs very rarely with the immune checkpoint inhibitors.

However, the latter can overstimulate your immune system where it can attack your normal cells and result in inflammation. Most commonly, inflammation can occur in the colon (colitis, causing severe diarrhea), skin (rash), lungs (pneumonitis), liver (hepatitis) endocrine (causing thyroid disorders or diabetes). All systems can be affected.

The adverse events can occur after the first dose or may be delayed for several months after stopping the immune therapy. Patients need to be aware that these effects may occur 4 to 6 months after therapy has been completed.

Immunotherapy has added another approach to the treatment of cancer.

However, it must be remembered that the side effects are different from traditional chemotherapy. Individuals may respond well to this type of therapy or not at all. This may depend on the person or the type of cancer.

Patients with autoimmune disorders should probably not receive this treatment and it should be discussed H with their physician. n

Submitted by Louiselle Godbout, The Ottawa Hospital NOVEMBER 2020 HOSPITAL NEWS 31

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

Understanding drug shortages during a pandemic

By Christina Adams or many years, hospital pharmacists and pharmacy technicians have been managing significant drug shortages in Canadian hospitals.

F

The reasons for drug shortages are complex and multifactorial. One of the simplest reasons for a drug shortage would be a shortage of the raw materials required to make the Active Pharmaceutical Ingredient (API).

Secondly, there could be a disruption

Supporting you during the challenges of COVID-19 At Fresenius Kabi Canada, our mission is caring for life and our purpose is to put lifesaving medicines in the hands of people who care for patients. Never has this been more important than it is today.

Right now we all might need to stand a few feet farther apart, but it is more important than ever that we stand together.

We are proud to work shoulder-to-shoulder with you to do everything we can to support the heroic and selfless actions on the front lines of COVID-19 patient care.

MKTG-002E-2020.10.26-1.2

32 HOSPITAL NEWS NOVEMBER 2020

in the supply chain, whereby some countries might close their borders temporarily or not be able to manufacture these medications at the same levels they were before. This was seen in the early weeks of the COVID-19 pandemic, when India temporarily halted export of medications and API, and when Chinese manufacturing capabilities were significantly impacted by the effect of the virus on their workforce.

A third issue is that over the last 2025 years, globalization, mergers, and acquisitions of drug companies have been significant, and the net result is fewer manufacturers for any given generic medication. If one of the four or five manufacturers left have an issue with their supply chain, it puts additional pressure on the others to make up for that lack of supply in the Canadian market.

Natural disasters are unpredictable and can have a huge impact on the supply chain. A shortage of minibags to mix intravenous medications had a huge impact on hospitals in North America in early 2018. This shortage could not have been foreseen but speaks to the fragility of the supply chain when one manufacturer has such an impact on the operation of so many hospitals.

Finally, increased demand can result in drug shortages. This is the core issue affecting Canada’s drug supply during the COVID-19 pandemic. An

unanticipated, significant increase in the demand for specific medications results in shortages because manufacturers cannot quickly ramp up production of these medications.

The globalization of the drug supply means that production schedules are established 12-18 months or more in advance, and quickly pivoting to increase production of a specific medication is not always possible in the timeframe required.

There are many stakeholders involved in managing drug shortages, and each has a specific role to ensure that the impact of drug shortages is minimized to the greatest extent possible. In hospitals, pharmacy managers and pharmacy technicians involved in drug distribution spend a considerable amount of time managing drug shortages. Some of the mitigating strategies are: to obtain different pack sizes or concentrations of backordered medications; to use other medications from the same therapeutic class; to compound medications in-house, if possible; to use medications from a different therapeutic class but with a similar mechanism of action; and, most significantly, to help determine which patient populations are prioritized for access to the limited supply of the medication.

Group purchasing organizations have a role in managing drug shortages for their member hospitals. They are the bridge between the hospitals www.hospitalnews.com

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS and suppliers and can request protective allocations be put in place if a critical medication is at risk of being in shortage. They work to ensure a fair allocation to as many hospitals as possible, and they also help to promote the sharing of any clinical guidance documents, alternative medication suggestions and mitigation strategies developed by their member hospitals.

Manufacturers have a role in managing drug shortages, and it starts with advising Health Canada of any impending shortages that they foresee. Manufacturers also participate on multi-stakeholder calls to have holistic discussions on the supply availability for any medications that are actually or potentially in shortage which would have a significant impact on the health of Canadians, and they work with their global partners to secure additional supply of a medication for the Canadian market, where possible.

UNFORTUNATELY, BECAUSE THE DRUG SUPPLY CHAIN IS SO COMPLEX, THERE IS NO SIMPLE SOLUTION TO THIS PROBLEM AND ANY MEASURES THAT ARE TAKEN WOULD HAVE TO INVOLVE LEGISLATIVE, REGULATORY, DIPLOMATIC, AND PRACTICAL CONSIDERATIONS. Health Canada has several options available to mitigate drug shortages.

When a medication is assessed as being critically important for Canadians and at risk of being unavailable, Health Canada can expedite Establishment License Review, Submission Review and Lot Release for medications. There is also the Special Access Program, which allows small-scale importation of medications not marketed in Canada. And in exceptional circumstances, such as the COVID-19 pandemic, an Interim

Order from the Minister of Health gives Health Canada additional flexibility in securing a stable drug supply for the Canadian market.

The Canadian Society of Hospital Pharmacists (CSHP) also has a role to play in mitigating drug shortages.

CSHP participates in calls with Health Canada and other stakeholders such as the Provinces and Territories, the manufacturers, the group purchasing organizations and other healthcare associations. These multi-stakehold-

er calls help to determine if a drug shortage will be considered critical, and they allow CSHP to gather and share information with their members.

CSHP also helps to bring attention to the issue so that the Canadian public understands the rationale for some of the decision-making around drug shortages.

Canadians would face less risk with their drug supply if effective measures could be put into place to reduce drug shortages. Unfortunately, because the drug supply chain is so complex, there is no simple solution to this problem and any measures that are taken would have to involve legislative, regulatory, diplomatic, and practical considerations. The COVID-19 pandemic has highlighted the amount of work involved in managing these shortages, and that stakeholders must work together to ensure that Canadians have the medications they need, when they H need them. n

Christina Adams is Chief Pharmacy Officer at CSHP.

Supporting you during the challenges of COVID-19 At Fresenius Kabi Canada, our mission is caring for life and our purpose is to put lifesaving medicines in the hands of people who care for patients. Never has this been more important than it is today.

Right now we all might need to stand a few feet farther apart, but it is more important than ever that we stand together. We are proud to work shoulder-toshoulder with you to do everything we can to support the heroic and selfless actions on the front lines of COVID-19 patient care.

MKTG 002E 2020.10.26 1.0

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

A Pharmacy Resident’s experience during the COVID-19 pandemic

By Christopher Chiu

GOING THROUGH A RESIDENCY PROGRAM HELPED ME DEVELOP THE CONFIDENCE TO COMMUNICATE MY ASSESSMENTS AND RECOMMENDATIONS TO OTHER HEALTHCARE PROVIDERS, AND ALLOWED ME TO THINK ON MY FEET IN ORDER TO QUICKLY PROBLEM-SOLVE.

I

f you asked me a year ago what I would be doing during my time as a Pharmacy Resident, never would I have imagined being redeployed on the front-lines amidst a global pandemic. A hospital residency program is a one-year post-graduate learning experience with rotations in pharmacy practice, education, research, and administration. As a Pharmacy Resident at the University Health Network in Toronto, I was more than halfway through my training with a focus in primary care when things took an unexpected turn.

The number of patients testing positive for COVID-19 was steadily growing in Toronto. I was completing my rotation at the Family Health Team (FHT), where both staff and patients were starting to adjust to the new normal for healthcare during a pandemic.

Although patients were still being seen at the FHT, a decrease in ambulatory clinic activity and changes in preceptor availability due to redeployment meant that there had to be a shifting of patient care and service needs. Because of this, I received news that my residency training would be put on hold. I was unsettled by the uncertainty of not knowing where I would be needed or when this pandemic would end.

Because of increased staffing needs, I was redeployed as a clinical pharmacist at the Toronto Rehabilitation Institute. In what seemed like a blink of

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an eye, I had to quickly adapt from being a learner to an independently practicing pharmacist. I was initially asked to care for patients in a temporary Alternate Level of Care (ALC) unit, which accepted patients from acute care hospitals while they awaited longterm care beds, in preparation for a potential surge of critically-ill patients with COVID-19. Thankfully, that surge never happened. I later spent most of my time working in the Musculoskeletal and Geriatric Rehabilitation Units, a fast-paced environment where patients with musculoskeletal injuries and other complex issues associated with aging were admitted.

The main difference was the level of independence that was expected from me. As a resident, I would discuss therapeutic recommendations with my preceptor and regularly receive feedback on my patient encounters. As a pharmacist, I was fully accountable for my own clinical decision making.

Having additional responsibilities was nerve wracking at first, but I soon realized that I had been preparing for this all along. Going through a residency program helped me develop the confidence to communicate my assessments and recommendations to other healthcare providers, and allowed me to think on my feet in order to quickly problem-solve. With that said, I never once felt alone and had plenty of support from my pharmacist colleagues whenever I had questions.

Another difference was the accelerated learning. As a recent graduate, I am constantly looking up new information, whether that be learning about unfamiliar disease states or appraising the literature for evidence-based rec-

ommendations. Being a pharmacist in a fast-paced inpatient unit and having a higher patient caseload meant I had to be deliberate and efficient with my information gathering. Nonetheless, being a lifelong learner means that you will never have all the answers, you just need to know where to find them!

One personal challenge was the fear of becoming infected. Every time I would come into the hospital, I had a tense feeling that everything and anyone I came into contact with was potentially infectious. This was due in part to the COVID-19 outbreaks within our institution and other healthcare colleagues who unfortunately tested positive. Although I am relatively young and healthy, the last thing I wanted was to transmit the virus to my older parents who have comorbidities.

This feeling gradually lessened over time and I did what I could to feel protected while at work. I was grateful to have access to personal protective equipment and to be working in a clinical area without direct contact with acutely-ill patients with COVID-19.

If I reflect on my time as a redeployed pharmacist, there are three key lessons that I will take away from this experience. First, is accepting what is out of my control. Part of being resilient is understanding that things often do not go as planned and that adapting to changing situations is important to overcome these obstacles. Second, is maintaining a positive attitude. Instead of ruminating on the negative aspects of the situation I was placed in, I began to embrace the opportunities that came my way. The final lesson I learned is making mental health a priority. Getting enough sleep, staying connected with loved ones, and finding temporary respites were so important in helping to manage my own stresses. In the end, this experience meant a lot for my personal and professional growth. Years from now, I will look back on the challenges and opportunities during my residency year, and remember how I rose to the occaH sion in these unprecedented times. n

Christopher Chiu, PharmD is a Pharmacy Resident at the University Health Network, Toronto, ON www.hospitalnews.com

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CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

Conserving drug supply during COVID-19:

How sterile compounding can help

By Vivian KT Lee

D

uring the COVID-19 pandemic, hospitals across Canada are proactively preparing for or responding to drug shortages, particularly of pharmaceuticals used in intensive care, palliative care and infectious diseases. One approach to conserve medication supply is sterile compounding done by trained, competent and tested personnel in a facility compliant with sterile non-hazardous compounding standards established by the National Association of Pharmacy Regulatory Authorities (NAPRA) and the U.S. Pharmacopoeia (USP). This article will discuss four general compounding approaches that may be considered.

1) REPACKAGING

Aliquoting – In this approach, a commercial product is being repackaged into smaller aliquots of compounded sterile products (CSPs). Aliquoting is helpful when a typical dose used in clinical practice is significantly smaller than what is provided in the commercial form.

Pooling – In this approach, multiple units of the same commercial product are combined in a desired larger container. This can help conserve supply

of the same product that is commercially available in that larger volume.

Repackaging is generally the simplest compounding approach because it does not alter the chemistry and hence stability of the original product.

Compatibility of the repackaged drug with the material of its new container however must be established by consulting appropriate stability resources such as Extended Stability for Parenteral Drugs, Trissel’s IV Compatibility, Stabilis and the American Hospital Formulary Service (AHFS).

2) DILUTION

When supply of a medication at a certain concentration becomes short, one may produce more units of that desired concentration by diluting a more concentrated commercial product. The compounder has one of three approaches to dilution: add the medication directly to a bag of diluent, remove an amount of diluent from the diluent bag prior to addition of the medication, or add specific amounts of drug and diluent to an empty container to achieve an exact concentration.

These approaches are further discussed in a guidance document published by the Institute for Safe Medication Practices (ISMP) Canada on the management of overfill in diluent bags.

Dilution is more complex than repackaging because stability must be established for the drug in the chosen diluent, concentration as well as in its final container.

3) FORMULATING A NEW CSP

When therapies of choice in a particular patient care area begin to dwindle, institutions must prepare to use second or third line options in order to continue to provide care. When these alternate options are not commercially available or attainable, one may consider formulating a CSP from a commercial product. An example is compounding hydromorphone continuous infusions as a second line option to fentanyl infusions used for analgesia and sedation in mechanically-ventilated patients. Formulating a new CSP can involve one or a combination of the compounding methods discussed above.

All of the above methods involve batching of multiple doses. Therefore, from the perspective of product sterility, they are categorized as Medium Risk Level compounding according to NAPRA standards. Medium Risk CSPs are permitted to have storage periods not exceeding 9 days in refrigeration and 30 hours at room temperature.

The final Beyond Use Date (BUD) as-

signed to the CSP must be the shorter of the period during which the CSP is chemically stable and the storage period specific to the risk category.

4) COMPOUNDING FROM RAW API

When commercial product is in short supply, institutions may consider compounding from raw active pharmaceutical ingredient (API) which is not typically sterile, also known as High Risk Level compounding according to NAPRA. This type of compounding must consider the addition of any necessary excipients to stabilize the final product such as solvents, pH buffers and preservatives, as well as implement terminal sterilization of the final CSP before it is appropriate for administration to the patient.

OTHER CONSERVATION STRATEGIES

Sterile drug delivery systems for nursing point-of-use in patient care areas can support use of longer BUDs, which in turn minimizes drug wastage before the BUD is reached. An example of such a system is Baxter Canada’s Mini-Bag Plus® docking system.

Anticipated increasing demand of certain drugs administered as intermittent infusions may be suited for such a

Layered Learning: A new approach to training

By Onella Pereira xperiential rotations are an integral component of undergraduate pharmacy curriculum to promote development of skills and consolidation of knowledge with the added benefit of real-world exposure to practice. However, the demand for training opportunities often outnumbers the availabilities of sites and preceptors to provide quality learning experiences. As such, traditional models of one-to-one preceptorship need to be reassessed in order to best utilize time and available resources.

E

For years now, medical schools across Canada and the United States have adopted the use of a layered learning practice model (LLPM) whereby resident physicians train medical students under the clinical expertise of an attending. It has become a useful education tool to allow for integration of more learners into one rotation.

In this “hierarchical” model, the senior preceptor is responsible for all learners providing oversight, guidance, and practice-specific expertise. The resident on the other hand assumes the role of the student’s primary preceptor developing learning objectives, facilitating daily clinical activities,

36 HOSPITAL NEWS NOVEMBER 2020

leading topic discussions, evaluating performance and providing feedback.

Application of multi-layered learning involves four main stages: 1. orientation for the preceptor and resident to the LLPM; 2. planning of rotation and activities by the resident; 3. implementation of proposed rotation and modifying experience(s) based on ongoing feedback and 4. post-experience evaluation of resident and student and obtaining feedback to revise future rotation(s).

Having had the opportunity to be a resident preceptor and a student to one, I am able to provide insight into the advantages and challenges

of LLPM. As a resident preceptor, this was a unique opportunity to improve my teaching skills, to coordinate meaningful learning experiences and to gain a know-how to providing constructive feedback. I felt more practice-ready, working independently to provide patient care. I was in an active leadership role but was still learning as much clinically during the rotation as my student. Being a preceptor was by-far a humbling experience. It was a first-hand glimpse into the hard yet delicate balancing act of managing a clinical roster, departmental responsibilities, and student learning at the same time. www.hospitalnews.com

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

system, such as anti-infectives used to treat bacterial pneumonias and possibly COVID-19 infections.

OTHER CONSIDERATIONS

Pandemic-related drug conservation through sterile compounding is most likely to be effective when implemented proactively and collaboratively. It is advisable that compounding strategies be considered before shortages of both drugs and personal protective equipment (PPE) are realized, to review CSPs that provide care across different service areas that rely on a single commercial pharmaceutical form, and to engage prescribers early in discussions to use alternate drug therapies that can be procured commercially or compounded. Consulting expertise from compounding personnel, medication safety and systems, nurses and nurse educators, pharmacy informatics and risk management will help ensure successful implementation of compounding-related conservation efforts during H this unprecedented time. n Vivian Lee, B.Sc.Phm., RPh is a Pharmacist in Emergency Medicine, Sterile Non-Hazardous Compounding at Peterborough Regional Health Centre.

As a student of LLPM, I was able to still benefit from one-to-one preceptorship (ie. focused discussions, individualized feedback) with the resident but with increased exposure to perspectives and clinical scenarios of the senior pharmacist. Having a resident as a preceptor seemed less intimidating and was a unique opportunity to foster mentorship. Given that many residents were most recently students as well, shared experiences can be useful to help students navigate and transition from case-based to practice-based learning.

This model serves of benefit to the

Opioid tapering in the context of COVID-19

By Andrew De Jong, Rohail Malhi Nawaz, and Naomi Steenhof

I

n this brief article, we will describe some principles of opioid tapering in the context of COVID-19.

TRUST

One of the most important elements for a successful opioid taper is the ability to develop a trusting relationship. Patients are referred for opioid tapering after seeing multiple healthcare providers, and if those encounters did not give them the relief they need there can be a sense of distrust from the beginning of the relationship (Sherman et al., 2018).

Initiating patients on an opioid taper can damage trust due to the associated side effects; therefore, building an initial connection is crucial. Additionally, patients are often wary that we are trying to take away the one medication that gives them some relief, so they need to believe that our strategies are developed with their overall health and interests in mind (Kennedy et al., 2017).

Pre-COVID-19, the pharmacist might have a long, in-person initial consultation to gather a full medication history, explore which tapering strategies have been tried in the past, and develop an individualized plan.

However, due to COVID-19, we have

senior preceptors as well. Redistribution of existing resources allows more time to be dedicated towards projects, initiatives, committees, and clinically directed patient activities that may have otherwise been foregone. Preceptors still have the ability to enjoy the fulfillment of providing support, mentorship and engaging with their learners, without significant time commitment and stress.

There are of course challenges to this model. For one, not all sites have residents. In this case, modifying LLPM to a near-learning model of having a

focused our time on supporting existing patients with short, frequent, virtual visits. Scheduling more frequent follow-up is preferable in the opioid tapering context because it allows us to develop a therapeutic relationship, monitor progress regularly, and modify plans if needed.

OPIOID TAPERING STRATEGIES

Many different options are appropriate for individuals with chronic pain who want to taper their opioids (Murphy et al., 2018). The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain recognizes that patients should be supported by clinicians to make decisions that are consistent with their values and preferences (Busse et al., 2017). However, rapidly pivoting to virtual care has meant that though the principles of opioid tapering remain the same, the ways that we can support our patients throughout the process has changed.

Provide clear and accurate education to your patient on what to expect when they decrease their opioid dose.

Most patients with chronic pain know their typical withdrawal symptoms; however, many patients may not realize that one of their first withdrawal symptoms is an increase in their over-

senior student be a mentor or coach to a junior student may be more appropriate. A method should also be in place to ensure clinical competencies of the resident are met prior to preceptorship to ensure that their practice is safe.

Less proficient residents will require more oversight and collaboration from the senior pharmacist. The success of layered learning also relies on success in all stages of application from orientation to implementation. Miscommunication regarding the roles, responsibilities and expectations of the senior preceptor and resident may cause

all body pain. This increase in pain may lead them to believe that their opioids were effective causing them to halt the taper. Explaining this phenomenon clearly, giving management options, and reassuring patients that most withdrawal effects subside after a couple of weeks is crucial for success.

Be flexible in adapting tapering schedules, especially during the pandemic. For some patients, the opportunity to work from home meant that they wanted to speed up the rate of their taper because they could manage their pain and withdrawal symptoms easier at home. However, other patients had increased stress, responsibilities, and pain, so we decided to pause their taper until they had regained some more stability in their life.

HOLISTIC APPROACH

Chronic pain is influenced by psychological and environmental factors that require a holistic approach to treatment. Pharmacists should consider social support, stress management, and physical activity during a comprehensive pain assessment.

When optimized, these three factors can improve the quality of life for patients suffering from chronic pain.

Continued on page 38

confusion and impact the experience of all parties involved. Implementation is also often challenging, especially for newer preceptors or residents in an inexperienced area.

As we look into the future of our practice, the layered learning model may serve as a valuable strategy to overcome barriers for resource limited sites with either residents or students with varying education levels in order to provide opportunities for preceptorship, increase exposure to clinical practice and increase capacity of expeH riential rotations. n

Onella Pereira RPh BSc, PharmD is a Pharmacy Resident at The Ottawa Hospital. www.hospitalnews.com

NOVEMBER 2020 HOSPITAL NEWS 37

CANADIAN SOCIETY OF HOSPITAL PHARMACISTS

The cannabis conundrum:

To continue or not to continue, that is the question

By Nancy Qiao n October 17th 2018, the Cannabis Act came into effect, giving millions of Canadians access to cannabis. The legalization of cannabis presents multiple new challenges to the Canadian healthcare system. Prior to October 17th 2018, patients could access cannabis for medical purposes with a medical document from an authorized prescriber. However, an increasing number of patients are accessing cannabis without medical authorization and the number of patients with medical authorization has plateaued since legalization. Not only is more research needed to better understand the physiological effects of medical cannabis but also new guidelines should be developed for cannabis management in patients admitted to hospital.

Cannabis comes from the cannabis sativa plant that originated in Asia. It can be used by many different routes,

O

including smoking/vaping, oral/sublingual, and transdermal. Typically, inhalation has the fastest onset of action but shortest duration of effect, whereas oral administration has a slower onset but longer duration of action. Regardless of the form of use, the therapeutic and psychoactive effects of cannabis come from a class of substances known as cannabinoids.

The two most common cannabinoids are tetrahydrocannabinol (THC) and cannabidiol (CBD). Of these substances, tetrahydrocannabinol (THC) contributes mainly to the “high” associated with cannabis use. In particular, THC achieves these effects by binding to the cannabinoid type 1 receptor of the peripheral and central nervous system.

The precise effects of these cannabinoids are still unclear, and no official Health Canada indication is currently available. However, there is moderate evidence for indications such as spasticity and muscle spasm due to mul-

Continued from page 37

Opioid tapering Recently, the COVID-19 pandemic has hindered the ability of individuals to engage in many components of holistic pain management.

For instance, requirements for physical and social distancing increases social isolation, which can worsen the degree to which pain interferes with daily living (Karayannis, Baumann, Sturgeon, Melloh, & Mackey, 2019). Reports of increased pain may be more pronounced in elderly individuals, particularly those who live alone, cannot visit with family, or who are unable to use technology for social interaction. Stress may also adversely impact chronic pain, and many patients are currently experiencing heightened anxiety stemming from job instability, health vulnerability, and disrup-

tions in their established routines.

Lastly, patients may now experience limited opportunities for physical activity with the closure of public recreational facilities such as pools, gyms, and parks.

When following up with patients, regularly ask about changes in lifestyle patterns that may contribute to worsened or unmanaged pain. Listen actively and encourage patients who might be struggling as a result of isolation or stress. Circumstances out of the patient’s control will be frustrating but having support and reassurance of a healthcare professional is critical for maintaining their trust.

Discussions may yield unseen insights to both the patient and pharmacist that are useful while developing a H management plan. n

Naomi Steenhof is a pharmacist who practices in a quaternary chronic pain clinic. Andrew De Jong and Rohail Malhi are pharmacy students.

38 HOSPITAL NEWS NOVEMBER 2020

tiple sclerosis, paraplegia, nausea and vomiting due to chemotherapy, chronic pain, and sleep disorders. Weaker evidence suggests that patients with an anxiety disorder, cancer related pain, and fibromyalgia can also benefit from cannabis use.

On the other hand, there are a number of side effects associated with cannabis consumption. These include drowsiness, impaired memory and attention span, disorientation and confusion, impaired motor skills, and irritation. The possibility of these side effects mean that cannabis should be used with caution in certain populations such as pediatric patients, patients having a history of hypersensitivity to cannabinoid products, those with severe cardiovascular disease, those with respiratory disease, patients with severe liver or kidney disease and those with a history of psychiatric disorders, history of substance abuse, and pregnancy/breastfeeding.

A 2019 Health Canada survey showed that 24.6 per cent of Canadians had used cannabis in the 12 months prior to the study. However, only 3.8 per cent of the respondents used cannabis for medical purposes with proper medical documentation while 10.5 per cent used cannabis for medical purposes without proper documentation.

With the increasing number of patients using cannabis without a medical document, healthcare providers need to answer the difficult question of whether to continue a patient’s cannabis for medical purposes on admission to

hospital if the patient had been using cannabis without documentation at home. Beyond the problem of proper documentation, healthcare professionals must also decide on the proper management of patients who are inhaling their cannabis at home as this is prohibited on hospital property due to provincial laws.

Currently, many hospitals do not have policies that outline procedures in these circumstances and many prohibit cannabis without proper medical documentation. As a result, the Canadian Society of Hospital Pharmacists (CSHP) formed a Cannabis Task Force to create a position statement and a best practice document. The Task Force has considered issues such as supply, strategies for patients who smoke/vape, administration, storage, education, clinical competency, and ethical considerations. CSHP encourages pharmacists to incorporate the assessment of cannabis as part of routine patient care. Pharmacists should maintain clinical competency to make decisions related to cannabis use. When approaching patients about their cannabis use, pharmacy professionals must be mindful of their own professional, ethical and moral positions regarding cannabis. Keeping any existing bias in mind, pharmacy professionals must always be objective and non-judgmental towards patients’ cannabis use. Cannabis remains a controversial topic but CHSP is working to assist hospital pharmacists in tackH ling this difficult clinical issue. n

Nancy Qiao is a Pharmacy Student at University of Toronto’s Leslie Dan Faculty of Pharmacy. www.hospitalnews.com

SAFE MEDICATION

Antimicrobial Stewardship in the face of COVID-19

By Peter Zhang, Corlissa Chan, and Certina Ho ith infectious diseases in the public spotlight, there is a growing recognition for the need of antimicrobial stewardship within and beyond the hospital setting.

Throughout this pandemic, COVID-19 has reminded us of how vulnerable we are without viable treatments against deadly microbes.

Without effective antimicrobial stewardship, this may, one day, be the eventuality of other types of infectious diseases.

Antimicrobial stewardship is the practice of ensuring that patients receive optimal antimicrobial therapy.

While stewardship is an important aspect of practice for any clinician, antimicrobial stewardship programs provide formal structure to this practice.

In addition to reducing antimicrobial resistance rates, stewardship programs protect patients from the adverse effects of unnecessary antimicrobial exposure. The growing role of stewardship in routine clinical care brings together interdisciplinary teams of healthcare professionals in the fight against the rise of antimicrobial resistance.

In recent years, the growing use of broad-spectrum antibiotics has resulted in increasingly resistant strains of bacteria. While all antibiotics can exert pressures that select for resistance, broad-spectrum antibiotics can exert this effect on bacteria beyond the ones responsible for the disease in question, leading to unnecessary increases in antibiotic resistance. As a result, infectious disease can become dangerously difficult to treat, as viable treatment options dwindle to fewer and fewer antimicrobial agents.

Research in this area has repeatedly shown that antimicrobial stewardship programs can reduce the use of broad-spectrum antibiotics. But what

W

do antimicrobial stewardship teams really do? And why are these programs important to the point of being required for hospital accreditation?

THE ANTIMICROBIAL STEWARDSHIP PROGRAM

On the stewardship team, pharmacists will review antimicrobial therapy to determine whether its use is appropriate on an ongoing basis. Appropriateness can take many forms. For example, a broad-spectrum antibiotic may be inappropriate when a specific pathogen has already been identified.

On the other hand, if the antibiotic therapy was too narrow, and did not cover the likely organisms involved, the stewardship team would intervene as well. This strategy ensures optimal patient care while reducing the unnecessary usage of antimicrobial agents.

Outside of direct patient care, stewardship teams also provide clinician education and resources. For example, stewardship teams generate hospital antibiograms, which will allow clinicians to assess local resistance patterns at their hospitals to make informed decisions on antibiotic therapy. Beyond this valuable tool, stewardship teams are often involved in academic research initiatives to investigate new ways of combating antimicrobial resistance.

and fewer new antibiotic agents are being developed to replace existing agents that are now less effective due to increasing resistance rates. With a growing number of once preventable infections becoming untreatable, appropriate antimicrobial usage is gradually being recognized.

The overuse of antibiotics has only been amplified with COVID-19, which carries with it a risk of bacterial co-infection. For example, a rapid review of the literature published in May 2020 revealed that 72per cent of hospitalized COVID-19 patients received antibiotics, but only 8per cent were seen to have co-infections of a bacterial or other non-viral source. This is of major concern, as the pandemic seems to aggravate unnecessary antibiotic use.

TAKING ACTION NOW

The dangers of antimicrobial resistance are clear, and effective antimicrobial stewardship programs are more important now than ever, especially with the increased usage of antibiotics during the COVID-19 pandemic. Targeted training for healthcare professionals to differentiate between severe COVID-19 cases and cases of co-infections involving bacterial non-viral sources is a potential intervention.

Without taking direct action against the rise of resistance, the prevalence of multi-drug resistant organisms will increase. The result will be a wide array of previously treatable diseases becoming untreatable, leading to millions of unnecessary deaths in the future. As the world prepares for future waves of the pandemic, clinicians need to be more diligent and be active members of antimicrobial stewardship programs .

RESOURCES FOR CANADIANS

The Public Health Agency of Canada recently published a Canada Communicable Disease Report (CCDR) in January 2020, featuring Antimicrobial Stewardship in Health Care Settings.

In addition, Using Antibiotics Wisely is a national campaign where tools and resources are available for healthcare professionals and patients to learn more about unnecessary and inappropriate antibiotic use in primary care, long-term care, and hospital care H settings. n

GLOBAL IMPACT

The global impact of antimicrobial resistance is staggering. In 2019, the United Nations Ad hoc Interagency Coordinating Group on Antimicrobial Resistance released a report and predicted that 10 million deaths per year will be attributed to antimicrobial resistance by 2050.

This is exacerbated by the fact that fewer

Peter Zhang is a combined PharmD/MBA Student at the Leslie Dan Faculty of Pharmacy (LDFP) and the Rotman School of Management, University of Toronto; Corlissa Chan is a PharmD Student at the LDFP, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and the LDFP, University of Toronto. www.hospitalnews.com

NOVEMBER 2020 HOSPITAL NEWS 39

Telepractice and equity

ETHICS

through the lens of a pandemic

By Andria Bianchi

I

n April 2018, I wrote about the ethics of e-health.

E-health is a term that encompasses various technological methods and platforms used for health purposes. One type of e-health is telemedicine, which when a clinician is at least one of the parties involved in a healthcare interaction occurring through technology. A related type of care is that of telepractice, which, according to the College of Nurses of Ontario, is “the delivery, management and coordination of care and services provided via information and telecommunication technologies”, presumably by clinicians and other members of a healthcare team.

At the time of the column’s publication (i.e., in 2018), telepractice services were on the rise, but they were far from the norm in terms of how care was being offered. In response to the COVID-19 pandemic, however, the tables abruptly turned. As we are all aware, the immediate response to the pandemic was for everyone to remain at home and to follow public health guidelines when outside of one’s residence. In the healthcare domain, many treatments and procedures were cancelled, but some appointments and interventions became available via telepractice. Ultimately, the pandemic forced our society to expedite the process of developing reliable telepractice options since many people were not allowed to and/or were unable to attend appointments in-person. And since it is likely that this method of care provision will be encouraged for the foreseeable future, it is important for us to explore the ethical benefits and to unpack potential harms in order to ensure that our society’s healthcare needs are being met effectively.

Some benefits of telemedicine (including telepractice) are noted in the 2018 column. For instance, being able to provide access to care for people

who live in remote and/or rural locations is one upside of telepractice. Prior to the pandemic, it would have been the case that some people would receive in-person support whereas others would be cared for through telepractice depending on their location. As a consequence, some people may have been disadvantaged insofar as telepractice options were rare and/or less ideal than receiving in-person care (although perhaps still better than no care at all). Because almost everyone is receiving care via telepractice in the current context, however, it may be the case that more equal care is provided across groups since everyone is given the same options irrespective of location.

Although more equal care may be provided amongst populations who can access telepractice, one of the challenges is that some of the most vulnerable and marginalized people in our society are plausibly the ones who may be unable to do so, thereby leading to increased inequity. While most people may be able to attend telepractice appointments, a person who is marginally housed may not. Relatedly, people who do not have a reliable internet connection and/or who cannot afford

a necessary device (e.g. a computer) and/or who are unable to navigate the technical complexities because of a cognitive impairment may be unable to benefit from this type of care.

The individuals in this position, i.e., those who may be unable to access and/or benefit from telepractice services because of socioeconomic, housing, and/or other factors, may be those who are experiencing health consequences from the social determinants of health (SDH). The World Health Organization defines the SDH as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” The idea behind the SDH is that a person’s place in society (e.g. their socioeconomic status, housing, education, employment, etc.) will inevitably influence their health. It is important to highlight that people suffering from the SDH may make up a large portion of individuals who cannot effectively utilize telepractice and who may be more likely to require care.

Insofar as some of society’s most vulnerable individuals may require

but be unable to access care, we ought to explore alternative options available. Can and/or should we provide people with devices (e.g. computers, phones)? Can and/or should we alter our provision of care such that we see specific members of our society in-person, outside, etc.? Can and/or should we prioritize addressing and spending resources on the SDH? If the answer to any of the above questions is “yes”, then implementing changes to our care provision in the current context may be worth considering.

Balancing the duty to provide effective individual care with that of public safety during a pandemic is difficult and complex. In performing this balancing act, however, it is important to be mindful of the most vulnerable individuals and to try to decrease inequities in addition to inequalities when it comes to care access. We may be able to do this in the current context by offering telepractice support and alternative care options.

Ultimately, our society’s response to COVID-19 ought to take into account the whole of society and make efforts to accommodate the most vulH nerable and in need. n

Andria Bianchi, PhD is a Bioethicist at University Health Network and an Assistant Professor (status-only) at the Dalla Lana School of Public Health – University of Toronto.

40 HOSPITAL NEWS NOVEMBER 2020

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NEWS

COVID-19 exposes crisis in palliative care, and a solution

alliative care was already at a capacity crisis point in Canada before COVID-19, but the pandemic has exposed an urgent need for additional training among front-line health providers caring for patients with progressive, life-limiting conditions.

Research shows three in five Canadian primary care physicians do not feel adequately prepared to help people in need of palliative care. Restrictions related to COVID-19 have only made a challenging situation worse, with many front-line providers finding themselves as the primary, and often only, source of palliative care for patients.

“During the pandemic the need for palliative care has increased significantly, as health providers care for two

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populations: patients with life-limiting conditions, and patients who become rapidly and terminally ill as a result of COVID-19,” says Jeffrey Moat, CEO of Pallium Canada, a national non-profit organization focused on building professional and community capacity to help improve the quality and accessibility of palliative care in Canada.

“We’ve long needed a systems approach, where we have specialist palliative care resources in adequate numbers, in the right places and in right proportion, as well as a strong primary level capacity,” he continues. “Family doctors, nurses, occupational therapists, physiotherapists, social workers and personal support workers all see patients who could benefit from palliative care, and all should have the skills to provide better care.”

Getting more health providers trained on the palliative care approach is critical. To address this need, Pallium Canada has partnered with Boehringer Ingelheim (Canada) Ltd., to launch a unique solution: a national education initiative called Bridging HOPE (Helping Others through Palliative care Education). The initiative was already well underway with live educational events across the country when COVID-19 hit, forcing the team to find a way to continue the effort amidst unprecedented disruption, uncertainty and physical isolation.

The solution? A series of live webinars, featuring over 40 palliative care experts and offered free of charge to health providers across the country.

Demand for the sessions, which are continuing, has been unprecedented.

In just six months, the Bridging Hope

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“COVID-19 Palliative Care Connect Initiative” has helped over 16,000 health providers across the country gain critical knowledge about managing palliative care. And the number of registrants continues to grow.

Moat believes that this innovative learning approach, which builds capacity and promotes earlier, more effective and more compassionate care, addresses a need that will only increase as the population ages and more people live with life-limiting, chronic illnesses for prolonged periods.

“It has the potential to significantly improve the way these patients are cared for, and also strengthen the provider-patient role,” says Moat.

He also believes palliative care training needs to be intensified in medical schools.

Continued on page 42

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Using research

NEWS

Crisis in palliative to find ways to support healthcare care

workers through the pandemic

By Kristi Lalonde

A

t no other time in recent history have healthcare workers across this country been so challenged.

COVID-19 has unsettled daily life for everyone including healthcare providers who already experience high stress, anxiety, and depression in their workplaces. Mental healthcare workers are known to be at especially high risk.

Waypoint Centre for Mental Health Care is a specialized mental health hospital located on the shores of Georgian Bay offering a wide-range of acute and longer-term inpatient and outpatient programs. The hospital also has the only high-secure forensic mental health program in Ontario. Providing treatment and care for these vulnerable populations has always been rewarding, but also multifaceted.

As pandemic restrictions continue and the number of cases rise again, healthcare providers must continue to shift their practices. This ongoing situation is impacting levels of stress, anxiety, and depression experienced by healthcare providers with concern arising for the delivery of mental health care.

An exploratory survey with healthcare workers at Waypoint conducted prior to the pandemic revealed burnout is prevalent. The study found that nearly 70 per cent of workers reported that at times they feel emotionally drained from the work they do. A recommendation from this study is the critical need for effective interventions to reduce burnout for frontline workers.

Waypoint already had robust wellness and psychological health, safety and wellness programming. However, the hospital recognized staff would need additional help given the pandemic. The hospital enhanced and increased access to resiliency work-

shops, enhanced traumatic incident support, and resource sharing, among other things. With an eye toward future supports, the Waypoint Research Institute also began two projects in partnership with Georgian College to benefit healthcare workers.

ECHOES, or Effects of COVID-19 on Healthcare Providers: Opportunities for Education and Support is a two part project. The first part uses research methods to understand the experiences of health care providers with the pandemic and how the pandemic is impacting the work they do with patients. Individual interviews and surveys provide healthcare workers with an opportunity to describe their current situation and to explain their ideas on additional resources that could help them. The second part of the project involves using this initial research to develop education and supports to improve wellness and abilities of these essential workers to continue delivering quality mental health care during the pandemic recovery.

The research team is working with the Waypoint Psychological Health, Safety and Wellness team to develop a plan to integrate and implement these tools to support Waypoint mental healthcare workers.

The second project will seek to improve psychological resiliency and overall mental health for frontline workers during COVID-19 and beyond with an online mindfulness skills program.

Building on the success of the Mindfulness Without Borders 12week face-to-face Mindfulness Ambassador education program offered at the hospital over the previous two years, this study seeks to understand the efficacy of a condensed online four-week version. The Canadian-developed standardized curriculum was specifically designed to strengthen communication skills, foster social connections, build empathy, prevent burnout and compassion fatigue, regulate emotions and develop resilience. The four-week Mindfulness Ambassador Program is being offered to healthcare workers across North Simcoe Muskoka, and participants will be given the opportunity to partake in this study. Little is known about the efficacy of online mindfulness programming, and to guide development of online mindfulness education, specifically in healthcare and mental healthcare.

No one could have predicted this pandemic would last this long, and we don’t know when it will end, but our healthcare providers must continue to provide essential mental health and addiction treatment and care.

Ultimately, the researchers hope the skills developed throughout this program will improve the mental wellbeing and resiliency of frontline workers throughout the pandemic and into the future. Improving the health of frontline workers will ensure they can continue to provide the community with the best care H possible. n

Continued from page 41

“Unfortunately, palliative care has received little attention in the past or inclusion in medical and nursing school curricula,” he says.

“As a result you have healthcare professionals who enter the system that don’t have the full set of skills to provide that palliative care approach to patients.”

As more front-line health providers are equipped with a better understanding of palliative care and some basic competencies, they will be able to identify earlier in an illness trajectory when patients can benefit from a palliative care approach. Learning this approach also benefits health care system, driving interdisciplinary collaboration and teamwork, better communication and compassion, more holistic whole person care, and better use of healthcare resources.

Early access to palliative care has been shown to be effective in reducing emergency department visits and intensive care unit stays at the end of life, according to the Canadian Institute for Health Information.

In some cases, palliative care practices not only improve a patients’ quality of life, but how long they live as well. Taken together, the palliative care approach is aligned with the wishes of most Canadians living with a life-limiting illness, who want to remain independent and receive the care they need at home or in their community, rather than spend their final days in a hospital.

“The Bridging HOPE initiative is an important part of our effort to foster innovative change and improve the health of Canadians,” says Andrea Sambati, President and CEO, Boehringer Ingelheim (Canada) Ltd. For more information please visit H www.Pallium.ca. n

Kristi Lalonde is a communications officer at Waypoint Centre for Mental Health Care.

42 HOSPITAL NEWS NOVEMBER 2020

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LONG-TERM CARE NEWS

November is Fall prevention month

By Marguerite Oberle Thomas and Alison Stirling ear of falling refers to persistent concern about having a fall that leads an individual to avoid daily activities. Patients may go to hospital after a fall and express that they will be more careful in the future. Part of that strategy may be to avoid activity, but health care practitioners want to promote the opposite. The theme for Fall Prevention Month 2020 is “Be Ready, Be Steady” – both as actions to counter the fear.

Is it a rational fear? Yes, the fear is based on reality. According to the Canadian Institute for Health Information (CIHI), 81 per cent of hospitalized injuries were due to falls in 2017-2018 with the majority for older adults age 65 and over. The balance to that fear needs to be informed motivation, not paralysis.

F

IN CANADA IN 2017–2018, 51 PER CNET OF ALL INJURY-RELATED HOSPITALIZATIONS WERE FOR SENIORS AGE 65+; 37 PER CENT OF THOSE HOSPITALIZATIONS WERE MALES WHILE 63 PER CENT WERE FEMALES: 81 PER CENT OF INJURY HOSPITALIZATIONS WERE DUE TO FALLS (SOURCE : CIHI).

Fear of falling may start earlier than expected. Middle aged and older adults who report a fear of falling share some factors. They are likely less physically active. Other factors can include limitations in daily activities, higher levels of anxiety and depression, chronic conditions, and the use of walking aids. Did fear of falling come first to limit mobility or did decreased mobility lead to fear of falling?

While hospitals are mandated to have fall prevention strategies in place for inpatients, it is for post discharge that you can use tips on how to communicate with older adults to encourage your patients to use multiple approaches: 1. Create a safe indoor environment.

Check out the fallpreventionmonth.ca for tips.

2. Be physically active.

3. Check out cognitive behaviour therapy to address fears of falling 4. Consider a medical alert button, 5. Teach patients how to get up from a fall.

6. Avoid letting fear of failing cause social isolation 7. Look into outdoor risk factors 8. Perform medication reviews as some drugs can affect fall risk 9. Optometrists recommend annual check-ups for everyone over 65 10. Check out the Fall Prevention Month website (adults and caregivers) for practical tips on safe winter walking including the Toronto Rehab Institute safe footwear site ratemytreads.

11.Encourage patients to drink plenty of fluids – dehydration can cause dizziness and lead H to falls n

Marguerite Oberle Thomas, RN., BScN., Consultant Liaison, and Alison Stirling, MHSc., MISt., Knowledge Broker, both seniors, work with Loop Fall Prevention Community of Practice of the Ontario Neurotrauma Foundation.

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LONG-TERM CARE NEWS

COVID-19 has significantly increased the use of technology among older Canadians

By Margaret Polanyi rom Facebook to food delivery apps and fitness trackers, older Canadians have upped their use of many technologies and online services during the COVID-19 pandemic.

A new AGE-WELL poll conducted

by Environics Research in July 2020 shows that two-thirds (65 %) of Canadians aged 65 and older now own a smartphone, compared to 58 per cent in 2019, and most who own one (83%) use it daily.

During the pandemic, seniors have increased their use of video calls as a way to communicate with family and friends. About a quarter (23%) of Canadians 65+ now use video-calling on their smartphones, twice as many as in 2019; six in 10 of whom report increased use due to COVID-19.

F

ABOUT A QUARTER (23%) OF CANADIANS 65+ NOW USE VIDEO-CALLING ON THEIR SMARTPHONES, TWICE AS MANY AS IN 2019.

When it comes to social media, so popular with a younger demographic, older adults are populating the platforms too. More than one-third (37%) use social media to communicate with family and friends. Over a quarter (29%) use it for “health, wellness and/ or independence” (of whom 42% report utilizing it more due to COVID-19).

And with many seniors staying at home more during COVID-19, two in 10 (19%) of Canadians 65+ are using online shopping for essential items,

like groceries, for “health, wellness and/or independence” (of whom six in 10 report utilizing it more due to COVID-19).

The survey shows that 72 per cent of Canadians aged 65+ feel confident using current technology.

“With these findings, we can set aside any notion that older adults are technophobic. Most are unfazed by technology and they are using a lot of it during these challenging times,” says Dr. Andrew Sixsmith, Scientific

Co-Director of AGE-WELL, Canada’s Technology and Aging Network. “We were already seeing older adults using more technology, but COVID-19 is clearly a catalyst that is taking tech use to a new level.”

The poll was conducted July 16 to 27, interviewing 2,026 Canadians 50 years of age and older, with 78 per cent participating via an online panel and 22 per cent contacted by telephone.

The survey also looks at the impact of COVID-19 on age-related concerns among older Canadians, who have been disproportionately affected by the pandemic. About half of respondents aged 50+ are now more concerned about health and about losing loved ones. Forty-six per cent are significantly or somewhat more concerned about moving to a nursing home, and 43%

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LONG-TERM CARE NEWS

ON THE POSITIVE SIDE, OVER TWO-THIRDS (66%) OF CANADIANS OVER 50 AGREE THAT TECHNOLOGICAL ADVANCEMENTS CAN HELP TO LESSEN THE IMPACT OF COVID-19 ON DAILY LIFE. feel that way about moving to a retirement home.

On the positive side, over two-thirds (66%) of Canadians over 50 agree that technological advancements can help to lessen the impact of COVID-19 on daily life. The majority agree that technological advances can help them maintain relationships with family and friends, reduce social isolation, pursue hobbies, manage health, maintain mental health and stay safe, independent and active as they age.

Olive Bryanton, 83, of Hampshire, Prince Edward Island, can’t imagine life in the time of COVID without technology. “It has kept me sane, especially in the early part when we couldn’t go

out and family couldn’t come to visit.” She’s been on Zoom “almost constantly” since COVID-19 began, participating in and presenting at virtual meetings and webinars, and connecting with family. She takes to Twitter and Facebook more often, and attended a wedding via livestream.

Among other survey findings: • 52 per cent of Canadians aged 50+ had a telehealth appointment in the past 3 months, and 79 per cent of those who had one were satisfied with it. Experience with video appointments is still limited (7%); • 48 per cent of Canadians over aged 50+ are optimistic about aging (compared to 56% in 2019);

• Technology that “manages independence” is most popular, with over half of users of techs/services such as wearable digital devices, online shopping for essential items, exercise/ activity trackers and webinars/online classes reporting a positive impact on their health and wellness.

“At a time when older adults face enormous challenges, it is encouraging to see that many are reaching for technologies, online services and apps to help. They are receptive to technology that allows them to stay in their own homes, and open to virtual health and virtual community with family and friends,” says Dr. Alex Mihailidis, AGEWELL Scientific Co-Director and CEO.

Central to all of this is ensuring that new technologies are user-friendly and practical, including for people with disabilities. “Despite the increasing use of technology by seniors, we need to remember that some people are still losing out and there is a digital divide between the technology haves and have-nots. We need to make sure that technologies are accessible, affordable and available to all. “ AGE-WELL commissioned a similar survey in 2019 of Canadians aged 50-64 and 65+. A number of pandemic-related questions were added to the 2020 poll. For more details, H visit www.agewell-nce.ca n

Margaret Polanyi is Senior Communications Manager at AGE-WELL, a federally-funded Network of Centres of Excellence.

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Virtual care strategy focuses on optimal experience

By Sarah Quadri ary is making important choices – at home. She’s been doing that for over 70 years.

“I choose survival, it’s always been that way for me,” says Mary, an artist, who makes her home in a 19th century, restored barn in Ontario. “As a baby, I was thrown between haystacks during the Second World War, when bombers flew over England. I am also a ‘phantom twin’ – I’m the one who survived; I am destined to survive.”

These days, Mary’s “survival” is about making the choice of how to receive care at home for a foot wound, during the pandemic. The wound is the result of a venous leg ulcer that developed post-surgery to repair her broken ankle, after she fractured it in the winter of 1995, when she fell while walking on a friend’s icy driveway.

The wound flares up every so often.

SE Health is nurturing Mary’s commitment to making “choices,” while caring for her wound. As her home care provider and one of Canada’s largest health care organizations, SE Health is keeping client choice at the forefront of delivering care, even during these uncertain times. Last March, when the pandemic began, SE Health was quick to mobilize their virtual care strategy, ensuring client’s like Mary had “choices” and confidence in receiving care.

“We strongly believe that home is the safest place to receive care – during a pandemic and always,” says Mary Lou Ackerman, Vice President of Innovation and Virtual Care Lead at SE Health. “This means understanding our clients’ concerns, as they relate to the pandemic and ensuring an optimal experience for our clients and staff by providing choices for how to receive that care. Care always comes first, that’s our commitment – for over 100 years.”

Keeping that “optimal experience” top of mind, SE Health’s virtual care

M

Melanie Brown (right), SE Health RPN, is proud to be delivering holistic care, ensuring the mental, emotional and physical well-being of her clients. strategy was developed with the intent to ensure that all clients continue to receive safe, quality and personalized care in the ways that work for them and their families, using communication tools they already feel comfortable with, such as the telephone, email, text and/or video.

“We’re extremely proud of our teams for collaborating and pivoting quickly to be able to offer our clients an outstanding virtual care experience that meets their care needs, promoting continuity in care and ensuring client and staff safety through physical distancing,” adds Ackerman.

For Mary, that care experience has been extraordinary. She began with in-person visits last November, but when the state of emergency went into effect, she was afraid.

“As the days passed, and COVID-19 became more serious, I could sense Mary was uncomfortable with having anyone in her home,” says Melanie Brown, SE Health Registered Practical Nurse and Mary’s care provider. “We embarked on a virtual care journey in early April and we haven’t looked back.”

“Melanie Brown is absolutely amazing; she’s the epitome of an excellent, caring nurse,” shared Mary.

“When I send her photos of the wound, she calls me on the telephone and we look at the photos together.

Melanie explains the measurement and presentation of the wound, if there’s been progress, any challenges we may be facing and step-by-step instructions on how to care for it. The support is wonderful.”

Mary is one of thousands of SE clients choosing (and benefiting from) virtual care. As such, SE Health is closely monitoring feedback and results.

“We are always looking for ways to reimagine care for our clients and families,” says Ackerman. “From our research and the feedback, we’ve noted that wound care, chronic disease management and palliative care are among the most common practices that fit well with virtual care. As autonomous practitioners, our nurses and therapists are well positioned to provide virtual care; they work independently, have incredible assessment skills, know the right questions to ask and use their clinical expertise to guide the client through their care needs.”

As for Mary, the results of her virtual care are outstanding in more ways than one.

“Mary’s original (vascular) wound, healed,” says Brown. “Our conversations also changed. In home and community care, the connection with our clients is always there because we are delivering care in people’s homes, but the connection became stronger, being in a pandemic and delivering care virtually,” adds Brown. “I’m proud to be delivering holistic care and ensuring the mental, emotional and physical well-being of my clients at all times.”

Now, with a combination of in-person and virtual care visits, Mary explained that she feels more “in charge” of her care and acknowledges SE Health’s commitment to client “choice” as critical in her care journey.

“Virtual care is the future and being able to choose how to receive that care is paramount. I often joke that I could be Melanie’s assistant as I now have the confidence to care for myself, at home. I made some mistakes along the way but I also got great results. It’s H a wonderful accomplishment.” n

Sarah Quadri is Director, Corporate Communications, SE Health & Elizz.

46 HOSPITAL NEWS NOVEMBER 2020

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For more information: Please consult the Product Monograph at https://www.tevacanada.com/globalassets/ canada-ph2/pdf-documents-en/specialty-pdfs/0620_truxima_pm_en.pdf for important information relating to contraindications, warnings, precautions, adverse reactions, drug interactions, dosing, administration (administered as an intravenous [IV] infusion through a dedicated line, not administered as an IV push or bolus) and conditions of clinical use, which have not been discussed in this piece. The Product Monograph is also available by calling Teva Canada Innovation at 1-833-662-5644. * Comparative clinical significance is unknown. † Please refer to the TRUXIMA® Product Monograph to see the complete list of NHL indications. ‡ Indications have been granted on the basis of similarity between TRUXIMA® and the reference biologic drug Rituxan®.

EU: European Union.

References: 1. Data on File. First to market rituximab biosimilar. Teva Canada. May 31, 2019. 2. TRUXIMA® Product Monograph. Teva Canada Limited. May 22, 2020. 3. IQVIA. Summary of study results. June 27, 2019. 4. Data on File.

Letter of attestation for EU indications of TRUXIMA®. July 9, 2019.

Rituxan® is a registered trademark of IDEC Pharmaceuticals Corporation, used under license.

Pr TRUXIMA® a registered trademark of Celltrion Healthcare Co., Ltd. 08/2021 © 2020 Teva Canada Innovation G.P. – S.E.N.C. Montreal, Quebec, H2Z 1S8 TRU20-ADH04E

Pr

Rituximab for Injection

10 mg/mL Intravenous Infusion