Hospital News August 2020 by Hospital News

Inside: From the CEO’s Desk | Evidence Matters | Safe Medication | Virtual Care | Paediatrics

August 2020 Edition

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Advocating for a

safe

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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! 1-866-768-1477 | www.healthcareproviders.ca

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Damage control. This pandemic has been hard on everyone on the front line. It’s as if we’re fighting two viruses: COVID-19, and the virus of disrespect so blatantly demonstrated by Doug Ford’s Conservatives. Bill 124 is punitive. It diminishes the value of our work and obstructs our access to fair bargaining and arbitration - at exactly the moment when we are stepping up to keep our communities safe during this pandemic. We’ve already battled through ten years of health-care underfunding by Liberal and Conservative governments. COVID-19 has exposed the serious consequences of the Ford government’s short-sightedness. Now new legislation, under bills 175 and 195, has further significant implications for nurses and health-care professionals. So we’ll keep on fighting on behalf of proper funding, safe staffing, and the public health-care system our patients deserve. And, we will continue to demand fair and equal treatment for our profession.

Contents August 2020 Edition

IN THIS ISSUE:

How do we prepare for the second wave?

▲ Cover story: Advocating for a safe return to school

▲ British Columbia’s health system response to COVID-19

▲ New virtual clinicc streamlines care forr COVID-19 patientss

COLUMNS Guest editorial .................4

In brief .............................6 Evidence matters ...........18 From the CEO’s desk .....24 Safe medication ............33 Long-term care ...............34

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▲ Virtual care project enhances care for Ontario’s tiniest patients

Researchers seek Canadian health care workers for study

COVID-19 shows support

for home care long overdue By Kelli Stajduhar, Tanya Sanders he global pandemic of COVID-19 has brought long-standing gaps in the Canadian care system sharply into focus, particularly for older adults who cannot live independently. As we collectively grasp the enormity of the troubling living conditions for Canada’s residents of long term care, and the resultant deaths due to to the pandemic, we must also consider how such tragedy could have been prevented – or at least minimized – in the first place. It has been almost 20 years since Roy Romanow led the Royal Commission on the Future of Health Care in Canada, highlighting an urgent need to build Canada’s home care programs. In 2009, the Canadian Healthcare Association published a road map for how to get there. And Canadians have repeatedly affirmed their wish to receive care ‘closer to home’ and forego the ever-expanding costs of institutional care. Too bad these calls for robust homecare services across the country have been largely ignored in favour of an inadequate piecemeal and patchwork system where few Canadians get the care they want or need. Of the almost $264 billion that we spend each year in Canada on health care, estimates suggest anywhere from three to nine billion of this is directed towards home and community care. Home care has never been encompassed under the Canada Health Act, and decades of cutbacks to fed-

eral health transfer payments under previous federal governments have shifted greater proportions of the costs of home care to the provinces. This has resulted in wide variation in what home care services look like across regions. We also routinely devalue the importance of home care in this country. Home support workers are often considered the lowest priority in contrast to other health care workers. During COVID-19, clients who receive home care, as well workers who provide the bulk of these services, are in many areas experiencing the effects of rationed access to personalized protective equipment (PPE). In some provinces, many clients have also experienced reduced access to some basic services – like bathing – that have (incredibly) been deemed ‘non-essential.’ Now imagine what life might have been like for today’s older Canadians had earlier recommendations for home care been implemented. We would have had, among other things, national home care standards, funding mechanisms and services to support older adults and persons with disabilities living at home or in alternate settings. We would have had decent support for Canada’s family caregivers, who provide the vast majority of support for those at home. Or imagine if Canada had adopted innovative home care programs used in other countries. Continued on page 6

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NEWS

Researchers seek Canadian health care workers

for study on moral distress during COVID-19 pandemic By Emilly Dubeau esearchers from Lawson Health Research Institute and the Centre of Excellence on PTSD and Related Mental Health Conditions are seeking 500 Canadian health care workers to participate in a study on moral distress and psychological wellbeing during the COVID-19 pandemic. Participants will complete online surveys once every three months for a total of 18 months. The goal is to better understand the pandemic’s impact on health care workers in order to minimize moral distress and support wellbeing during future pandemic events. Moral distress is a form of psychological distress that occurs following an event that conflicts with a person’s moral values or standards. Through previous research with military populations, moral distress has been linked to an increased risk of post-traumatic stress disorder (PTSD) and depression. “Health care workers are facing unprecedented demands as a result of the pandemic and many may be working under extreme physical and psychological stress,” says Dr. Don Richardson, Lawson Associate Scientist and Director of the MacDonald Franklin Operational Stress Injury (OSI) Research Centre. “Health care workers may face difficult moral-ethical decisions including those around patient care and shortages of personal protective equipment (PPE), which could lead to moral distress.” The study will consist of a series of surveys to assess moral distress during the pandemic. Participating health care workers will answer questions about moral-ethical dilemmas and

symptoms of depression, PTSD, general anxiety, and burnout. “Moral-ethical dilemmas must be considered in the context of other difficulties faced by health care workers during the pandemic, such as increased workloads, reduced social activities, and evolving work environments and health care delivery models,” explains Dr. Anthony Nazarov, Associate Scientist at Lawson and the MacDonald Franklin OSI Research Centre. The team hopes that results can be used to cultivate wellness at the outset of future pandemics. This might include guiding emergency preparedness policies and moral-ethical decision-making training modules. They hope that by tracking psychological outcomes over time, they can identify early warning signs of distress that can be targeted with early interventions. The researchers will also ask questions that explore how the pandemic is impacting health care delivery, such as increased reliance on virtual care appointments, and whether health care workers are satisfied with these changes. “It is necessary to provide a voice to health care workers during this pandemic,” adds Dr. Richardson. “This is the first study to measure the moral-ethical dilemmas faced in a pandemic and the impacts of such dilemmas on moral distress. It is also the first to measure health care worker perceptions on the virtual migration of patient care.” Interested Canadian health care workers can learn more about the study and access the survey at https:// H participaid.co/studies/bYE4Ob. ■

Emilly Dubeau is a Consultant, Communications & External Relations at Lawson Health Research Institute. www.hospitalnews.com

THE STUDY WILL CONSIST OF A SERIES OF SURVEYS TO ASSESS MORAL DISTRESS DURING THE PANDEMIC. PARTICIPATING HEALTH CARE WORKERS WILL ANSWER QUESTIONS ABOUT MORAL-ETHICAL DILEMMAS AND SYMPTOMS OF DEPRESSION, PTSD, GENERAL ANXIETY, AND BURNOUT.

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AUGUST 2020 HOSPITAL NEWS 5

IN BRIEF

For-profit long-term care homes and COVID-19 risk or-profit status is associated with the extent of an outbreak of coronavirus disease 2019 (COVID-19) in long-term care (LTC) homes and the number of resident deaths from COVID-19, but not the likelihood of an outbreak, which was related to the infection rate in the surrounding local public health unit and the total number of beds in the home, found new research published in CMAJ (Canadian Medical Association Journal). “Our findings suggest that the incidence of COVID-19 in the public health unit region surrounding an LTC home and the size of the home – but not for-profit status – are important risk

factors for outbreaks of COVID-19 in LTC homes, whereas for-profit status (with for-profit homes more commonly having outdated design standards and chain ownership) is an important risk factor for transmission of SARS-CoV-2 after an outbreak has been established in a home,” writes Dr. Nathan Stall, Sinai Health and the University of Toronto, with coauthors. The study looked at all 623 long-term care homes in Ontario from March 29 to May 20, 2020, and their 75,676 residents. It excluded retirement residences, which are privately funded and not administered by the Ministry of Long-term Care. For-profit homes were usually smaller, housed fewer residents,

COVID-19 shows support We could have had self-managed nursing teams in each neighbourhood in the country, providing care to everyone who needs it. The Buurtzorg model in Netherlands has demonstrated lower costs, higher patient satisfaction, higher professional satisfaction and improved outcomes for those in need of care. We could have also had highly integrated housing and heath-care policies that would ensure the right level of support is put in place for each older adult over time so that those who want to stay home can do so safely. That is what Denmark managed to implement as a part of its public universal health care system. Instead, Canada has opted for a remarkably uninspiring “status-quo” over the past several decades. Well before the COVID-19 crisis, the home care sector has been showing very clear signs of strain and dysfunction. Home care nurses in our research told us that home care is in a state of disarray. They face mounting pressures to get people with increasingly complex medical and social care

Continued from page 4

needs out of hospitals without any substantial investment in publicly funded home care. Nurses also told us they are under constant pressure to speed up and limit their services and even ration the care they provide. Could all of the deaths from COVID-19 in Canada’s long term care system have been prevented? Probably not. But if Canada had something more in place, perhaps most older Canadians would not require help within institutional settings in the first place. Our seniors and persons with disabilities deserve something more than what is essentially a patchwork system of subsidized and user-pay home care services and something more than pushing family caregivers to breaking points. In these unprecedented times, we have the opportunity to fundamentally re-think how we care for some of our most vulnerable Canadians. To ignore this opportunity only serves to perpetuate the ongoing inequities H that exist in our care system. ■

Kelli Stajduhar is a Professor School of Nursing and Research Affiliate at the Institute on Aging and Lifelong Health, University of Victoria and a Fellow of the Canadian Academy of Health Sciences. Tanya Sanders is a PhD Student, University of Victoria and Associate Teaching Professor, Thompson Rivers University School of Nursing. 6 HOSPITAL NEWS AUGUST 2020

and had older design standards from before 1972 with multiple-occupancy rooms and chain ownership. About 30 per cent (190) of long-term care homes in Ontario experienced outbreaks during the study period, with 110 (30.6%) occurring in for-profit homes, 55 (34%) in nonprofit homes and 25 (24.8%) in municipal homes. For-profit status of LTC homes was associated with about a two-fold increase in the extent of a COVID-19 outbreak (number of resident cases) and a 178 per cent increase in the number of resident deaths compared with homes with non-profit status. These associations were mediated in large part by the higher proportion of outdated design standards (which meet or fall below standards set in the year 1972) and chain ownership in for-profit homes. Of the 10 homes with the highest death rates, seven were for-profit-homes with older design standards and chain ownership. “Newer design standards provide for larger and more private room accommodations, as well as less crowded and self-contained common spaces, whereas older design standards can have wardstyle accommodation and centralized common spaces in which all residents can interact. Beyond promoting quality of life, newer design standards promote

infection prevention and control, given that they limit infection both within resident bedrooms and among areas of a facility,” write the authors. “With governments such as Ontario’s already committing to independent commissions and inquiries into their LTC systems, it is important that policy recommendations and changes consider all root causes of the present crisis, including supporting capital projects to retrofit or rebuild older LTC homes,” the authors write. In a related commentary, Dr. Margaret McGregor and co-author write “85 per cent of Ontario’s for-profit LTC facilities are part of a chain (v. 31% of nonprofit, and no chains among municipally run homes), which begs the question of whether for-profit chain status of a facility is a significant and independent risk factor for more extensive outbreaks and deaths, even after. If so, simply ensuring building upgrades, while important, is unlikely to be enough to address systemic deficiencies.” The commentary authors point to research that indicates that inadequate staffing, particularly at for-profit LTC homes, is associated with worse outcomes for patients in these facilities. They suggest governments should also focus on staffing levels when preparing H for the next wave of COVID-19. ■

Study is first to identify potential therapeutic targets for COVID-19 team from Lawson Health Research Institute and Western University are the first in the world to profile the body’s immune response to COVID-19. By studying blood samples from critically ill patients at London Health Sciences Centre (LHSC), the research team identified a unique pattern of six molecules that could be used as therapeutic targets to treat the virus. The study wass published in Critical Care Explorations. Since the pandemic’s start there have been reports that the immune

system can overreact to the virus and cause a cytokine storm – elevated levels of inflammatory molecules that damage healthy cells. “Clinicians have been trying to address this hyperinflammation but without evidence of what to target,” explains Dr. Douglas Fraser, lead researcher from Lawson and Western’s Schulich School of Medicine & Dentistry and Critical Care Physician at LHSC. “Our study takes away the guessing by identifying potential therapeutic targets for the first time.” Continued on page 7 www.hospitalnews.com

IN BRIEF

Challenges in evaluating SARS-CoV-2 vaccines

ith more than 140 SARSCoV-2 vaccines in development, the race is on for a successful candidate to help prevent COVID-19. An effective and safe vaccine would be a major advance in the fight against COVID-19. However, there are challenges in evaluating the efficacy of these vaccines during the pandemic, as an analysis article outlines in CMAJ (Canadian Medical Association Journal). Those evaluating vaccine efficacy must take into account the risk of infection in the population being studied, use of social distancing practices, rates of pre-existing immunity from earlier COVID-19 and factors that influence the likelihood of severe COVID-19. “The dynamic and rapidly changing pattern of virus exposure and level of population immunity during the evolving pandemic are potentially important confounders in the assessment of the efficacy of SARS-CoV-2 vaccines,” writes Dr. Bahaa Abu-Raya, BC Children’s Hospital, Vancouver, British Columbia, with coauthors. “This should be considered in sample size calculations for efficacy trials.”

SOME CONSIDERATIONS:

• Adequate sample sizes are needed to demonstrate effect of a vaccine in reducing disease and may need to be revised based on rates of SAR-CoV-2 transmission in study populations. • Public health interventions such as social distancing may reduce trans-

Therapeutic targets

Continued from page 6

The study included 30 participants: 10 COVID-19 patients and 10 patients with other infections admitted to LHSC’s intensive care unit (ICU), as well as 10 healthy control participants. Blood was drawn daily for the first seven days of ICU admission, processed in a lab and then analyzed using statistical methods and artificial intelligence (AI). The research team studied 57 inflammatory molecules. They found that six molecules were uniquely elevated in COVID-19 ICU patients (tumor necrowww.hospitalnews.com

mission and affect ongoing assessment of SARS-CoV-2 vaccines. • The baseline level of immunity could influence a trial outcome. For example, the benefit of a highly efficacious vaccine may not be evident in a population with high levels of previous exposure later in the pandemic. • There is a possibility that COVID-19 might be more severe in some people who have been vaccinated (called antibody-dependent enhancement [ADE]). This should be monitored as vaccine-related ADE may be evident only after large numbers of vaccinated people have been exposed to the virus and followed for some time. The authors emphasize the need to test vaccines in vulnerable populations such as seniors, health care workers, Black people and those with risk factors for severe disease and who may have a different response than younger, healthier trial participants. “The changing dynamics of the COVID-19 pandemic present a unique challenge for evaluating vaccines for SARS-CoV-2,” says author Dr. Manish Sadarangani, Director of the Vaccine Evaluation Center at BC Children’s Hospital and Sauder Family Chair in Pediatric Infectious Diseases at the University of British Columbia. “Researchers need to understand the immune responses generated after infection with this virus and whether they are protective, as this will help to inform the development and evaluation of these H vaccines.” ■

sis factor, granzyme B, heat shock protein 70, interleukin-18, interferon-gamma-inducible protein 10 and elastase 2). The team also used AI to validate their results. They found that inflammation profiling was able to predict the presence of COVID-19 in critically ill patients with 98 per cent accuracy. They also found that one of the molecules (heat shock protein 70) was strongly associated with an increased risk of death when measured in the H blood early during the illness. ■

Risk of preterm birth higher in women with kidney dysfunction omen with prepregnancy kidney dysfunction are at increased risk of preterm (premature) birth and other complications, especially women with chronic kidney disease, found new research published in CMAJ (Canadian Medical Association Journal). Preterm birth before 37 weeks’ gestation occurs in six to 11 per cent of viable pregnancies and is the leading cause of infant death. “The timely recognition of prepregnancy kidney dysfunction has several potential benefits, including informed counselling about the risk of adverse perinatal outcomes, closer monitoring of mother and fetus in pregnancy and potential use of acetylsalicylic acid to prevent preeclampsia,” writes Dr. Ziv Harel, St. Michael’s Hospital, Toronto, Ontario, with coauthors. In a large study of almost 56,000 pregnancies in Ontario, Canada, there was a nine per cent rate of preterm birth before 37 weeks’ gestation in women with kidney dysfunction compared with seven per cent in women

with normal kidney function. The mean maternal age was 30.7 years, 26 per cent were non-White, and 46 per cent were pregnant with their first child. The risk of severe preterm birth at or before 32 weeks was about doubled in women with kidney dysfunction. Of all the preterm births, 57 per cent (2255) were initiated by the health care provider and the remaining 43 per cent (1701) were spontaneous. The conclusions from previous research on this topic have been inconsistent, and the sample sizes of studies have often been small. The authors suggest that measuring some women’s serum creatinine before pregnancy may provide clinicians a novel way to assess the risk of preterm birth. “Given that measurement of serum creatinine is a readily available and inexpensive blood test, there may be a role for screening potentially high-risk women for kidney dysfunction either before conception or in the first half of H pregnancy,” they conclude. ■

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NEWS

The need for speed in sequencing

SARS-CoV-2 genomes By Andrew G. McArthur ince its emergence in Wuhan, China, in December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people worldwide including hundreds of thousands of deaths. In Canada the numbers are 110,000 cases and 8,850 deaths. As superbug resistance and the growing global scourge of COVID-19 places modern medicine under siege, somewhere in the trillions of data points processed at McMaster’s McArthur Lab, there’s a new drug or vaccine waiting to be discovered as well as a wealth of information on how COVID-19 spreads in our communities. Jalees Nasir, a PhD candidate in biochemistry and biomedical sciences at McMaster, has been working with McMaster and Sunnybrook Health Sciences Centre researchers to develop a tool that can specifically isolate respiratory viruses. When news broke of COVID-19, Nasir developed a sequence recipe to help researchers isolate the novel virus more easily. The gene sequencing system is a set of molecular ‘fishing hooks’ that isolate the virus, SARS-CoV-2, from biological samples, allowing McMaster’s researchers to gain insight into the virus through next-generation sequencing. Using data, and backed by modern technology infrastructure, the data generated by the tool, designed for the international health sciences community can help determine how the virus that causes COVID-19 is spreading and whether it is evolving. Virus genome sequences can be used to determine how the virus changes over time, how it transmits between people and how well it survives outside the body – it can help scientists understand if

TECHNOLOGY OVERALL, RESEARCHERS ARE CONSTANTLY HOLDS THE KEY ON THE LOOKOUT FOR NOVEL MUTATIONS AND The technology being used for this project wasn’t available during the FORTUNATELY THIS VIRUS MUTATES SARS outbreak in Canada in 2003. It VERY SLOWLY. takes a lot of data storage, supercomthe virus has evolved between patient A and patient B. When our researchers get samples from a patient, they can contain a mixture of virus, bacteria and human material, but we’re really only interested in the virus. It’s like a fishing expedition. The McArthur Lab designed baits that can be added to samples as hooks and pull out the virus from that mixture. The standard technique to isolate the virus requires culturing it in cells in labs by trained specialists. The new tool gives a faster, safer, easier and less-expensive alternative. Not every municipality or country has specialized labs and researchers, not to mention that culturing a virus is dangerous. The idea behind the tool is to remove some of the barriers and

allow for more widespread testing and analyses. Overall, researchers are constantly on the lookout for novel mutations and fortunately this virus mutates very slowly. That makes molecular contact tracing difficult so labs are moving to harder methods for outbreaks, but it also means the virus may not evade drugs or vaccines developed – which is promising. Data is critical to the daily insights in the lab. The lab’s data generation doubles every three months. The vast and growing amount of information relies on near-instant processing times. To manage sequence data, the lab relies on a modern storage system that can see between 600 to 1,000 strains go through the computer systems each day during a pandemic wave.

puter analysis and resources to run the comparisons among the 28,000 individual markers that make up a genome for SARS-CoV-2 so that cases can be traced backward and linked to the ones that came before. Working with industry-leading technology is key. There’s no point in playing with traditional computer infrastructure or storage because it’s just not fast enough for this work. In 2018, the lab started using a Pure Storage FlashBlade, the most advanced file and object storage designed to support highly complex processes. This sped up the time to research and seek cures for superbugs. When COVID-19 hit, The lab was able to pivot immediately and leverage the modern infrastructure already in place, allowing researchers to stay ahead of the curve as we fight global threats to human health and gain insight into the virus H through next-generation sequencing. ■

Andrew McArthur Ph.D., serves on the national CanCOGeN SARS-CoV-2 Viral Genome Sequencing Working Group and the Steering Committee for the Ontario Coronavirus Genomics Coalition (ONCoV.org) and his group produced the SIGNAL pipeline for Illumina-based sequencing of SARS-CoV-2 and flow of data to the Public Health Agency of Canada. Dr. McArthur and his team were part of the group to isolate the live virus and also developed a novel genotyping tool along with the Vector Institute: Read in the Lancet. 8 HOSPITAL NEWS AUGUST 2020

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COVID-19 :

How Autonomous Cleaning Solutions Improve Cleaning Results and Help Keep Workers Safe The outbreak of COVID-19 has put a spotlight on the importance of cleanliness. It has also resulted in much-deserved recognition and respect for the people who work to keep spaces like healthcare facilities clean and hygienic. For these professionals to maintain the desired level of clean, they need the right tools, including equipment that will enable them to clean efficiently, effectively, and safely. That’s why more institutions, from hospitals to high schools, are welcoming autonomous scrubber dryers into their cleaning fleet. Benefits of autonomous solutions for coronavirus-related cleaning Right now, cleaning is more important than ever, especially in areas where COVID-19 may be present. There are a multitude of tasks to complete, and the people who do those tasks must be kept safe while they work. In such environments, the main benefits of autonomous solutions are threefold: 2. Effectiveness. By following staffprogrammed paths without deviation, autonomous floorcare solutions can regularly deliver between 98% and 99.5% coverage. Our research shows that when operators use standard floorcare equipment, they typically miss about 15% of a space without meaning to. Given current public-health concerns, every floor should be cleaned from corner to corner – a goal more easily achieved with autonomous equipment.

3. Worker safety. Autonomous solutions signiﬁcantly reduce, and may even eliminate, the amount of time staff members spend in areas where germs may be present. Once a route is programmed into a machine, the machine will clean that same route every time, with no human intervention required. When the cleaning route is completed, or the machine needs assistance, it will notify the operator via SMS alerts.

Nilfisk is here to support cleaning teams that work tirelessly to fight the spread of COVID-19. The Liberty SC50 Autonomous Scrubber is the only third-party certified autonomous scrubber in the world. If you have any questions about autonomous solutions or cleaning during this time, please contact us at info@nilfisk-advance.ca

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1. Efficiency. In many buildings, floorcare is a major undertaking. Even for a skilled operator using a ride-on scrubber dryer, the job can take several hours – hours that could be spent on more detail-oriented objectives. But an autonomous machine gives staff the ability to focus on other tasks that benefit from extra effort. Now, instead of cleaning the floor, that same operator can spend those hours cleaning and disinfecting door handles, light switches, restroom fixtures, and other high-contact surfaces.

NEWS

British Columbia’s health system response

to COVID-19 pandemic from a Public Health Physician By Dr. Victoria Lee ritish Columbia (BC) managed to flatten then bend the COVID-19 curve. Some of this may be due to luck and some due to being prepared. BC has certainly benefited from strong provincial leadership and exemplary communication from the Provincial Health Officer, Dr. Bonnie Henry, and the Minister of Health, Hon. Adrian Dix. I believe the way in which BC’s health system is organized, with the Ministry of Health, two provincial and five regional health authorities, also played a significant role. Having experienced SARS, the H1N1 pandemic, avian influenza, Ebola and an opioid overdose crisis in different roles and settings, I know that these emergencies test the capabilities of our health system and, at the same time, test our society to reveal our strengths and vulnerabilities. I offer the following observations from a unique vantage point as a public health physician with comparative health system knowledge now serving as the CEO and president of a large health service organization – Fraser Health. Fraser Health serves over 1.8 million people across 20 diverse municipalities, 32 First Nations and five Métis chartered communities. Nearly 90 per cent of refugees and over 40 per cent of newcomers to BC settle in the Fraser Health region. As one of five regional health authorities in BC, Fraser Health provides a wide range of health services – 12 acute care hospitals as well as community-based long-term care, home health, mental health and public health services. As of June 16, 2020, over 51 per cent of COVID-19 cases in BC were in our region.

1) Integrated health system responses played a critical role in preparing for and responding to outbreaks in high-risk settings The Fraser Health region includes 203 owned and operated, contracted, and private Long-Term Care (LTC), Assisted Living (AL), and 10 HOSPITAL NEWS AUGUST 2020

Dr. Victoria Lee Independent Living (IL) facilities. As of June 20, 2020, there had been 22 COVID-19 outbreaks in these three settings. Establishing a region-wide and integrated coordination centre with LTC-AL-IL, home health, infection prevention and control (IPC), communication and public health (PH) was essential in ensuring both large scale and coordinated responses. With the regional coordination centre, enhanced prevention and outbreak management strategies were promptly developed, communicated and reinforced with a Public Health Order. Bi-weekly communication forums took place with all providers to problem-solve. Most importantly, proactive supports and prevention audits covered the full continuum from acute to community services. Some examples include medical advisory committees, training of nurses to acquire nasopharyngeal swabbing competency, critical care supports and deployment of SWAT teams within 12-24 hours (infection prevention ex-

pert, clinical nurse educator, patient care and quality, screeners, public health). 2) Acute care capacity was well protected throughout COVID-19 response and now into recovery There are 12 hospitals in the Fraser Health region with 2618 beds including 134 in critical care. Based on provincial modeling work across the Korea, Hubei and Italy scenarios, we utilized regional networks to develop extensive pandemic planning for critical care and acute care. This included preparing for the worst-case scenario by finding an additional 350 beds within existing capacity across all sites as well as in a new hospital that was under construction and at a LTC facility. During the COVID-19 response period from March to May, we maintained acute care occupancy at 50-70 per cent and critical care at 60-90 percent. This required the coordinated efforts of the full system including a nearly 52 per cent decrease

in visits made to hospitals by LTC patients, historic lows in CTAS (Canadian Triage Acuity System) 4s and 5s and a significant reduction of Alternate Level of Care (ALC) days (41 per cent). This was enabled by mobilizing regional transfers, enhancing home support/home health services, partnering with divisions of family practice, rapidly accelerating virtual health services for ambulatory services and postponing elective surgeries and procedures. It absolutely required support and sacrifice from our patients, families and communities, and we are grateful for the part they have played in our response. 3) Regional structures and processes enabled rapid decision-making and mobilization of resources There are 40,000 staff, medical staff and volunteers who work in the Fraser Health region. As the pandemic progressed, emergency operations centre (EOC) structures were promptly implemented. Mobilizing www.hospitalnews.com

NEWS

Human Resources to ensure adequate staffing has proven to be critical to not only providing safe care for patients but also to protecting our providers. During the pandemic response, Fraser Health hired over 600 staff, trained over 400 existing physicians and staff, deployed over 480 staff to vulnerable settings such as LTC-IL-AL sites through SWAT teams and deployed over 230 staff to facilities to ensure direct care was provided in outbreak facilities. In addition, central coordination of resources enabled reviewing staffing information for 15,449 employees of LTC-AL-IL facilities, and then implementing a single site order for those facilities, affecting 3,165 staff. Provincially and nationally pro-

cured Personal Protective Equipment (PPE) was distributed in settings that normally procure their own such supplies. In addition, our experts in public health, primary care, critical care and infection prevention and control rapidly mobilized both virtual and onsite support in the largest federal corrections outbreak that occurred in Mission Institution. 4) Partnerships protected some of the most vulnerable populations in highrisk settings Partnerships with divisions of family practice and family physicians enabled the establishment of 11 testing and assessment sites for COVID-19. Mass testing occurred in settings that we do

not normally work directly in such as meat processing plants and federal correctional facilities. Working with BC Housing and municipalities, emergency coordination and isolation centres were established to protect street-entrenched populations. Municipalities, foundations and auxiliaries were instrumental in garnering community and philanthropic supports. Frequent channels of communication were established to promote engagement and decision-making. There is no perfect design for health services. In fact, there are varying strengths and weaknesses in how we structure our health system. During the COVID-19 pandemic, the regional health authority structure was

beneficial in demonstrating flexibility and agility, addressing existing and long-standing silos in the health system, rapidly connecting experts across public health to critical care, enabling daily and weekly communication with widely-ranging internal and external stakeholders groups and reducing timelines from decision-making to scalable actions in clinical and operational areas. I am grateful to BCâ&#x20AC;&#x2122;s leaders at all levels of government, my health authority leadership counterparts, my Fraser Health colleagues, the staff and medical staff, and all of our partners who continue to work collectively with dedication, compassion and humility to provide the best care possible to our H patients, families and communities. â&#x2013;

Dr. Victoria Lee is President and CEO of Fraser Health, and as such leads the overall management and delivery of health programs and services in one of the largest and fastest-growing health networks in Canada. Prior to joining Fraser Health she worked in collaboration with national and international organizations including the United Nations Development Programme and the World Bank in the areas of comparative health systems, health policy, health financing and ecohealth.

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How do we prepare for the

NEWS

second wave? By Alexa Giorgi

t’s a question heard often now that a majority of the world has navigated through its first wave of SARS-CoV-2, the virus that causes COVID-19. After several months of deploying a variety of public health measures – from full lockdown to aggressive testing and contact tracing – to slow the transmission of the disease, the daily number of reported COVID-related cases and deaths are continuously declining in a number of countries, including Canada. And though these victories are to be celebrated, the current slowdown in COVID’s urgency has experts asking: “What worked?” “What didn’t?” and “What do we need for next time?” At UHN, researchers are finding the public health measures that were put in place in a country may matter less than the over-arching infrastructure to support them. In a study published July 21 in The Lancet’s journal EClinicalMedicine, Dr. Sheila Riazi and her team found that a country’s Global Health Security Index (GHS) – which includes government actions, the country’s preparedness and socioeconomic factors – is a significant indicator for the number of deaths a country experienced from COVID-19. “What’s unique about our research is that we used a country-level model incorporating data from 50 different countries to compare country-specific socioeconomic factors and healthcare capabilities on COVID-19-related outcomes,” says Dr. Riazi, an anesthesiologist at UHN’s Toronto Western Hospital and the principle investigator of the study. “What we found is that a country’s social and economic policies were as important, if not more so, than the public health measures taken to mitigate COVID-19. “National preparedness, as measured by GHS, tells us how prepared a nation is to face a pandemic prior to it coming while public health policies are formed

Photo credit:UHN

A research team led by Dr. Sheila Riazi, an anesthesiologist at Toronto Western Hospital, found that when it came to the number of deaths from COVID-19, a country’s social and economic policies were as important, if not more so, than the public health measures taken to mitigate the virus. The study is published in The Lancet’s EClinicalMedicine today. to face the biological threat once it arrives, such as social distancing, universal masks, mandated vaccinations,” she explains.

TALE OF TWO COUNTRIES – CANADA AND THE UNITED STATES

“Of course travel restrictions and containment measures such as testing and physical distancing all play significant roles in reducing the number of affected individuals, but they aren’t very effective in reducing the critical cases or mortality of the disease. “Instead, low levels of national preparedness in early detection and reporting, limited healthcare capacity, and population characteristics such as advanced age, obesity and higher unemployment rates were key factors associated with increased viral spread and overall mortality.”

The GHS index is made up of six categories, all of which had crucial roles in supporting measures against COVID-19: • Prevention • Detection and reporting • Rapid response • Health system • Compliance with international norms • Risk environment Dr. Riazi cites the tale of two countries – Canada and the United States, often regarded as relatively similar – to show the role of infrastructure in practice. “In Canada, there was early support for testing, ensuring manageable capacity in our healthcare system as well as implementing financial policies to support people so they would stay at home,” she explains. “Of course, the pandemic played out differently in long-term care which needs to be addressed but, otherwise, we did really well.”

“In the U.S., initial focus was on travel restrictions for visitors which may have helped with cases in the short term. While the U.S. ranked as the country with highest GHS score, during the pandemic the categories that make up the GHS index were not implemented as planned. “Testing was slow to ramp up and the economic policies weren’t enough to encourage people to stay home,” Dr. Riazi continues. “So here you have two countries with advanced health systems, but when it came to COVID-19, it was crucial to have the right health structures in place – the agencies to support the public health measures. “Our research has shown that, globally, these areas of support matter,” she concludes. “While we consider what is needed to face a second or third wave or even a new pandemic, these are the things H focus on.” ■

Alexa Giorgi is a Senior Public Affairs Advisor at University Health Network. 12 HOSPITAL NEWS AUGUST 2020

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NEWS

Pilot program helps patients experiencing homelessness and addiction during COVID-19 By Jennifer Stranges

Kate MacWilliams, Molly Schoo and Sandy Santos (left to right) of the Interprofessional Resource Team at St. Joseph’s Health Centre are devising wellness supports for their colleagues during COVID-19.

Staff provide wellness supports to team caring for inpatients with COVID-19 By Anna Wassermann hen a team of health care workers at St. Joseph’s Health Centre was redeployed to care for some of the hospital’s patients with COVID-19, it was the team’s wellness that their leaders were focused on. The Interprofessional Resource team (IRT) is a group of more than 80 registered nurses, registered practical nurses and allied health that provides support to units needing additional staff. Since mid-March, the team has been working on the hospital’s COVID-19 surge units, caring for inpatients who test positive for COVID-19 outside of the Emergency Department and Intensive Care Unit. “It’s challenging work,” says Kate MacWilliams, Manager of the Interprofessional Resource team. “Everyone comes into work with such a positive attitude but deep down, we know that many of our staff are dealing with acute stress and anxiety.” From the team’s earliest days on the COVID-19 units, MacWilliams and Sandy Santos, Patient Care Manager of the units, said they worried about staff wellness. To ensure the team felt supported, the duo organized debriefs at the biweekly IRT staff meetings and

a session with a representative from COMpsych, Unity Health’s Employee Assistance Program provider. Around the same time, Molly Schoo, Registered Dietitian on the IRT, began working on her own wellness projects for her colleagues. She started posting wellness resources, supports, podcasts and webinars on a shared online drive. She also designed flyers and posters for the units, each one containing an assortment of positive quotes and messages that could be torn off and presented to fellow team members. “In such a difficult time, I felt the need for positivity,” says Schoo, whose commitment to staff wellness and altruistic nature earned her the title of Wellness Ambassador. “I’ve always been the type of person who likes motivational quotes and lifting up others. I thought, why not express it?” Though Schoo’s actions helped lighten the mood on the units, MacWilliams said that she and Santos still wanted to do more; they wanted regular, frequent and professional support for their team. They reached out to their Chaplain, Lecia Kiska, and without hesitation, Kiska and the Spiritual Care team offered to support dai-

any people are turning to substances to cope with the isolation and uncertainty of the COVID-19 pandemic, putting additional strain on emergency services, says Dr. Alexander Caudarella, an addictions physician at St. Michael’s Hospital. In fact, data show more Torontonians died of suspected overdoses in April 2020 than any other month since Sept. 2017. But a pilot project in the St. Michael’s emergency department (ED) is assigning extra clinical support in the ED to ensure patients experiencing homelessness with complex health issues, including substance use, continue to receive a dignified and robust quality of care during the COVID-19 pandemic, while taking pressure off of the ED. “At a time of increased social isolation, decreased services and a tragic spike in overdoses, we have received really positive feedback from patients and community providers,” says Dr. Caudarella, who is also one of the leads of the pilot program, along with fellow Unity Health Toronto physicians Dr. Michelle Klaiman, Dr. Evelyn Dell and Dr. Kit Fairgrieve. The Pandemic Inner City Health Emergency Department (PICH-ED) program is a collaboration between St. Michael’s ED, the department of mental health, the family medicine team and a group of concerned community clinic physicians from the neighborhood. The project has pulled in extra physicians, family physician residents, social workers and nursing staff to emergency department shifts, so that high-risk patients with substance use issues are given comprehensive medical attention. Continued on page 15

ly mindfulness huddles on the units. For nearly a month now, the team has been meeting with a spiritual care practitioner for a mindfulness session and debrief each morning. These sessions have been particularly helpful when the team needs someone to talk to about a difficult case or a critically ill patient. “These supports have been so important and really well received and we’re grateful to the Spiritual Care team for making this possible,” says Santos. “The last couple of weeks have been busy and stressful but the team still shows up. Attendance and participation say a lot.” Santos says the practices they have in place are the least they can do to support their people. “They’re incredible and they’ve gone through so much,” she says. “Whatever they need, we’re here to support them.” Echoing Santos’ sentiment, MacWilliams says she can’t thank the group enough. “When the pandemic first began, people were stressed and worried but everyone has done an amazing job,” she says. “It’s our job now to continue H supporting them through it.” ■

Anna Wassermann is a communications advisor at Unity Health Toronto. 14 HOSPITAL NEWS AUGUST 2020

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NEWS Continued from page 14 “We know that people who use drugs and alcohol are at a high risk of leaving hospital before finishing their medical treatment,” says Dr. Caudarella. “In addition to dangerous outcomes for individuals, this represents a significant public health risk during COVID. The PICH-ED team is there to help ensure everyone can access treatment and feels comfortable staying in hospital to get the care they need.” “We have also been implementing a rapid response following overdoses to help start life-saving addiction treatment and reduce risk of future fatal overdose.” Dr. Carolyn Snider, chief of St. Michael’s emergency department, says the PICH-ED team has been essential in providing support to both her team and this vulnerable patient population.

THE PANDEMIC INNER CITY HEALTH EMERGENCY DEPARTMENT (PICH-ED) PROGRAM IS A COLLABORATION BETWEEN ST. MICHAEL’S ED, THE DEPARTMENT OF MENTAL HEALTH, THE FAMILY MEDICINE TEAM AND A GROUP OF CONCERNED COMMUNITY CLINIC PHYSICIANS FROM THE NEIGHBORHOOD. “This interdisciplinary group of emergency physicians, addictions physicians, social workers, ED and mental health nurses and community services workers are dedicated to provide care to the many patients who are experiencing homelessness in this challenging time.” In addition to alleviating pressure from the hospital’s emergency department, the PICH-ED has provided a training opportunity to family medi-

cine residents. Many family medicine residents pivoted their service to the emergency department when the pandemic began. “The pandemic inevitably disrupted the scheduled learning experiences planned for the family medicine residents in our training program,” says Dr. MaryBeth DeRocher, a family physician and postgraduate director of family medicine at St. Michael’s. “We were thrilled to collaborate with

the ED and mental health and addictions departments to have our family medicine residents provide care to the most vulnerable during these exceptionally chaotic times.” Dr. DeRocher explained that residents have oscillated between delivering direct care to patients with acute substance use issues in the ED, to addressing the more chronic health needs or preventative health measures. It’s been an opportunity for resident doctors to understand the impact COVID-19 is having on an already marginalized population and the unique skills required to support them. “Residents have described it as opportunity to actually do something when it felt like in-person clinical care was slipping away. Many have described their experience in the ED as H invigorating and deeply meaningful.” ■

Jennifer Stranges is a communications advisor at Unity Health Toronto.

Are you new to Canada? / Nouvellement arrivé(e) au Canada? Ž ǇŽƵ ǁĂŶƚ ƚŽ ŝŵƉƌŽǀĞ ǇŽƵƌ ǁŽƌŬƉůĂĐĞ ĐŽŵŵƵŶŝĐĂƟ ŽŶ ƐŬŝůůƐ͍ WĂƌƚŝĐŝƉĂƚĞ ŝŶ ĨƌĞĞ KĐĐƵƉĂƚŝŽŶͲƐƉĞĐŝĨŝĐ >ĂŶŐƵĂŐĞ dƌĂŝŶŝŶŐ ĐŽƵƌƐĞƐ tŽƌŬƉůĂĐĞ ŽŵŵƵŶŝĐĂƟ ŽŶ ^ŬŝůůƐ ĨŽƌ ,ĞĂůƚŚ ĂƌĞ

tŽƌŬƉůĂĐĞ ŽŵŵƵŶŝĐĂƟ ŽŶ ^ŬŝůůƐ ĨŽƌ /ŶƚĞƌƉƌŽĨĞƐƐŝŽŶĂů ,ĞĂůƚŚ ĂƌĞ dĞĂŵƐ

ͻ ĞŶƚĂů ,ǇŐŝĞŶŝƐƚ ͻDĞĚŝĐĂů >ĂďŽƌĂƚŽƌǇ dĞĐŚŶŽůŽŐŝƐƚ ͻDĞĚŝĐĂů ZĂĚŝĂƟ ŽŶ dĞĐŚŶŽůŽŐŝƐƚ ͻEƵƌƐĞ ͻWĞƌƐŽŶĂů ^ƵƉƉŽƌƚ tŽƌŬĞƌ ͻ^ůĞĞƉ dĞĐŚŶŽůŽŐŝƐƚ

ͻ ŝĞƟ Ɵ ĂŶ ͻEƵƌƐĞ ͻKĐĐƵƉĂƟ ŽŶĂů dŚĞƌĂƉŝƐƚ ͻWŚǇƐŝŽƚŚĞƌĂƉŝƐƚ ͻ^ŽĐŝĂů tŽƌŬĞƌ

&Žƌ ŵŽƌĞ ŝŶĨŽƌŵĂƟ ŽŶ ǀŝƐŝƚ ŚƩ Ɖ͗ͬͬǁǁǁ͘ĐŽͲŽƐůƚ͘ŽƌŐ dŽ ƋƵĂůŝĨǇ͕ ǇŽƵ ŵƵƐƚ ŚĂǀĞ ƚƌĂŝŶŝŶŐ Žƌ ĞǆƉĞƌŝĞŶĐĞ ŝŶ ƚŚĞ Į ĞůĚƐ ůŝƐƚĞĚ ƵŶĚĞƌ ĞĂĐŚ ĐŽƵƌƐĞ ĂďŽǀĞ͘ ůƐŽ͕ ǇŽƵ ŵƵƐƚ ďĞ Ă permanent ƌĞƐŝĚĞŶƚ ŽĨ ĂŶĂĚĂ Žƌ ƉƌŽƚĞĐƚĞĚ ƉĞƌƐŽŶ ĂŶĚ ǇŽƵƌ ŶŐůŝƐŚͬ&ƌĞŶĐŚ ŵƵƐƚ ďĞ Ăƚ ĂŶ intermediate level ; ĂŶĂĚŝĂŶ >ĂŶŐƵĂŐĞ ĞŶĐŚŵĂƌŬ ϲ ʹ ϴ ĨŽƌ ĐŽƵƌƐĞƐ ĚĞůŝǀĞƌĞĚ /Ŷ ŶŐůŝƐŚ Žƌ EŝǀĞĂƵǆ ĚĞ ĐŽŵƉĠƚĞŶĐĞ ůŝŶŐƵŝƐƟ ƋƵĞ ĐĂŶĂĚŝĞŶƐ ϲ ʹ ϴ ĨŽƌ ĐŽƵƌƐĞƐ ĚĞůŝǀĞƌĞĚ ŝŶ &ƌĞŶĐŚͿ͘

NEWS

New initiative helps hospitals re-engage family caregivers s hospitals re-open access for family caregivers, the Ontario Caregiver Organization (OCO) has a new tool kit that supports healthcare teams, patients and caregivers, featuring caregiver identification and a joint pledge that outlines health and safety accountabilities to protect patients, staff, physicians and caregivers. Developed in consultation with the Ontario Hospital Association (OHA) and in partnership with The Change Foundation and family caregivers, OCO’s new Partners in Care Tool Kit is already in use in select Ontario hospital and health-care facilities. Hospitals can download the tool kit from

the OCO’s website and customize the resources to reflect the circumstances and policies of each hospital. Resources include: • Caregiver Identification, including a template which can be used to create Caregiver ID badges or stickers as a visible way to identify caregivers who have been screened, trained in using personal protective equipment (PPE) and authorized to enter the hospital. Caregiver ID is an initiative of The Change Foundation and its Changing CARE projects. • A Partners in Care Pledge which outlines the accountabilities of the hospital staff, physicians and caregivers together in protecting their shared safety.

• “What caregivers can expect”, an overview of what family caregivers can expect when they arrive at the hospital, including PPE use, screening questions and how to address questions or concerns. These tools can be posted on the hospital’s website or distributed directly to family caregivers. “As access restrictions ease in hospitals and other health-care settings, there is a real opportunity to re-engage caregivers in a meaningful way while fulfilling a shared responsibility for safety,” says Amy Coupal, Chief Executive Officer of The Ontario Caregiver Organization. “The Partners in Care tool kit can support that process, while also mit-

igating COVID-19-related risks in the hospital.” “Health-care providers and family caregivers have experienced significant challenges during this unprecedented time,” adds Coupal, who points to the hashtag #NotJustAVisitor that reveals the extent and nature of some of these challenges. “Our Partners in Care initiative aims to reinforce the vital link between hospital staff and caregivers and help ensure they can work collectively to support they people for whom they care.” As the pandemic continues, the Partners in Care tool kit will help ensure caregivers can continue as essential care partners.

Specialized COVID-19 rehab and recovery program By Selma Al-Samarrai atients who require orthopaedic and amputee rehabilitation still require these specialized services – even if they have COVID-19. Rising to meet this need, Providence Healthcare, a hospital known for its excellent rehabilitation services, opened a brand new COVID-19 positive rehab and recovery program in April designed to care for COVID-19 positive patients. “When we were first approached about this COVID-19 unit, a lot of things ran through my mind, but the first thought was this is an emergency situation and we need to be prepared to care for our patients,” says Caroline Monteiro, the Patient Care Manager for the Orthopaedic and Amputee Rehabilitation unit on B5, which has three pods: north, south and west. She was called upon to help lead this space in the north pod. “The team was completely on board, and there was so much support from our

Laura Chiriac (left) and Emily Strauss are two of the B5 team members who came together to prepare this new space. colleagues at St. Michael’s and St. Joseph’s. It has been wonderful to see how all of our Unity Health sites have come together in response to this pandemic.”

The rehab and recovery program provides orthopaedic and amputee rehabilitation support with safety measures in place for positive patients including

an entirely isolated space with dedicated equipment and occupational therapy, physiotherapy, rehab and nursing support. Laura Chiriac, a Registered Nurse and one of the team members who helped create the space, said she is glad to be on the team providing this type of support. “Patients coming to us may be frail, exhausted, lonely from being away from loved ones and afraid of what’s next,” she says. “During these times, I hope that our knowledge, care and compassion will be what they need to feel supported as they get stronger and healthier.” Monteiro echoed those comments, saying her whole team is prepared and happy to help patients so they can get back to their normal as soon as possible. “I am so grateful for this opportunity to serve our community right now,” she says, “and for every single one of our team members for providing this H important support.” ■

Selma Al-Samarrai is a communications advisor at Unity Health Toronto. 16 HOSPITAL NEWS AUGUST 2020

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NEWS

CAREGIVER ID AND CLEAR EXPECTATIONS FOSTER SAFE, PRODUCTIVE PARTNERSHIPS

One of the first health-care facilities to adopt Caregiver ID was the Huron Perth Healthcare Alliance (HPHA), which implemented it as soon as COVID-19 visitor restrictions took effect. “The culture of family caregivers as partners is firmly embedded at HPHA,” explains Anne Campbell, recently retired VP, Partnerships and Chief Nurse Executive at HPHA. “When COVID-19 hit, it was a chaotic time, but we knew we had to maintain our commitment to patient-centred care.” According to HPHA, the highly visual badge identification has proven advantageous, clearly identifying essential family caregivers throughout

AS ACCESS RESTRICTIONS EASE IN HOSPITALS AND OTHER HEALTH-CARE SETTINGS, THERE IS A REAL OPPORTUNITY TO RE-ENGAGE CAREGIVERS IN A MEANINGFUL WAY the building, recognizing their unique role in patient care, and reassuring staff, physicians and patients, particularly during a time of heightened anxiety and uncertainty. “The Caregiver ID badge was an important part of our process. It was recognition of the family member as an essential caregiver and for staff it was validation that the caregiver was been screened and trained to use PPE” says Michelle Jones, Corporate Lead, Patient Experience & Privacy at HPHA.

FEELS LIKE A TEAM

Meanwhile, the Partners in Care resources are also welcomed by caregivers.

Charlene O’Reilly is a full-time caregiver, supporting her son whose rare genetic mutation disorder means he requires constant attention. She explains that being clearly identified as a caregiver helps in her daily interactions with medical staff. “It helps distinguish my role from that of a regular visitor and helps ensure that everyone meets the expectations for safety and great care,” says O’Reilly. “And, it helps reassure medical staff that I am there to participate in discussions with the medical team about care strategies for my son. It feels like a team.”

The Partners in Care tool kit is just the latest initiative to support the crucial relationship between healthcare facilities and caregivers. Earlier this year, OCO collaborated with the OHA on a shared ‘tip sheet’ that outlines what hospital staff want caregivers to know and vice versa. OCO also maintains a range of other resources for hospitals and health care providers, including guidance on such topics as communicating effectively with caregivers, discharge planning, health record sharing and more. “Hospital and health care providers are increasingly aware of the unique and vital role that family caregivers play in supporting effective and compassionate patient care,” says Coupal. “Our aim is to facilitate constructive relationships, with family caregivers as active partners in care within hospital settings and decision making, even H during a pandemic.” ■

This article was provided by the Ontario Caregiver Association

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EVIDENCE MATTERS

Can antibodies in the blood of recovered individuals help COVID-19 patients?

A review of the evidence on convalescent plasma therapy By Dr. Brit Cooper-Jones n March 11, 2020, the World Health Organization declared COVID-19 to be a global pandemic. Given the magnitude of this public health crisis and the fact that there are currently no known effective drug treatments or vaccines for COVID-19, there is great interest in exploring other potential treatment options such as convalescent plasma. And what exactly is convalescent plasma? It is an intervention where plasma (the liquid portion of blood that excludes red blood cells, white blood cells, platelets, and other cellular components) is collected from a recovered COVID-19 patient and then transferred into a patient with an active infection. The theory is that the COVID-19 antibodies (the disease-specific immune molecules) from the recovered individual could help facilitate the recovery of the patient who is actively infected. Convalescent plasma has been used to treat other types of infections in the past, such as diphtheria, scarlet fever, pertussis and the Spanish flu. However, as promising as the treatment might sound, it isn’t without risks. Because the treatment requires a blood transfusion (from the recovered individual to the patient with an active COVID-19 infection), all of the risks associated with blood transfusions also come into play here (e.g., anaphylaxis, transfusion related lung injury, transfusion associated circulatory overload, transmission of infections). Therefore, it becomes a matter of determining how effective and safe the treatment is, whether the benefits outweigh the risks, and which situations (if any) may warrant the use of convalescent plasma as a treatment for COVID-19. Currently in Canada there is one clinical trial underway investigating

THE THEORY IS THAT THE COVID-19 ANTIBODIES (THE DISEASE-SPECIFIC IMMUNE MOLECULES) FROM THE RECOVERED INDIVIDUAL COULD HELP FACILITATE THE RECOVERY OF THE PATIENT WHO IS ACTIVELY INFECTED. the use of convalescent plasma for the treatment of COVID-19 – the CONCOR-1 trial. This trial is including patients from over 50 hospitals across Canada, and preliminary results are expected to be available at the end of October 2020. But until then, is there other research we can draw upon to better understand the potential effectiveness and safety of convalescent plasma for COVID-19? To help answer this question, the health care community turned to CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – to find out what the evidence says. According to CADTH’s recently published report on this topic, the evidence on the effectiveness of convalescent plasma therapy for the treatment of COVID-19 is currently still in the

early stages. CADTH identified one randomized controlled trial and two non-randomized studies that compared the clinical effectiveness of convalescent plasma to the current standard of care. While the studies showed some potential promise with convalescent plasma (e.g., two studies reported higher rates of viral clearance, one study suggested a lower mortality rate [but the other two studies found no difference in mortality], and one study showed that patients survived longer with convalescent plasma), the quality of evidence was overall too low to draw any firm conclusions. The main limitations with the current body of evidence are the lack of high-quality clinical trials and the high risk of bias (due to the study designs; the small sample sizes; and the fact that both the patients who received convalescent plasma and those who didn’t

all received standard care, making it difficult to discern if an improvement in health status was the result of convalescent plasma therapy or of another treatment). With regards to safety, the studies reported a total of two non-severe adverse events in patients who received convalescent plasma (out of a total of 53 patients) – but again, the limitations of the study designs and small sample sizes must be considered. At the current time, while convalescent plasma shows promise as a treatment for COVID-19, additional high-quality research is needed to better inform decisions around its use. Fortunately, many clinical trials further investigating convalescent plasma therapy for COVID-19 are currently underway around the globe. Appendix 6 in CADTH’s report outlines the details of these trials. CADTH will also continue to update its convalescent plasma review monthly as a “living review” to ensure that it continues to reflect the latest evidence as it emerges. Finally, if convalescent plasma were to be implemented in a more widespread way in the future, additional implementation considerations would need to include: the availability and eligibility criteria for donors; the prioritization and eligibility criteria for recipients (since availability of convalescent plasma is anticipated to be a barrier); the economic and budgetary impacts; and ethical, equity, and safety considerations. Subscribe to New at CADTH (cadth.ca/subscribe) to stay updated on CADTH’s latest reports, including updates to the convalescent plasma review. If you would like to learn more about CADTH, visit cadth.ca, follow us on Twitter @CADTH_ACTMS, or speak to a Liaison Officer in your reH gion: cadth.ca/Liaison-Officers ■

Dr. Brit Cooper-Jones, MD is a Knowledge Mobilization Officer at CADTH. 18 HOSPITAL NEWS AUGUST 2020

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Jim walks the walk.

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

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PAEDIATRICS

The best care for kids

starts with advocating for a safe return to school By Dr. Ronald Cohn he COVID-19 pandemic has caused us all to re-evaluate how and where we care for our patients. From ramping up virtual health visits to contingency planning for a surge of COVID-19 infections to the rapid deployment of assessment centres in communities hit hard by the virus, we have truly shown patient care doesn’t just happen at the bedside. In fact, some of the most important care we provide may not take place on our hospital wards at all. Throughout the pandemic, we have heard from politicians, public health officials, business owners, economists, frontline workers, among others (I’m sure many of you who are reading this have been participating in the public discourse and I applaud you for doing so!). But there is a group of voices that has gone unheard for many, many months – our children and youth. We have a duty to uphold the highest standards of excellence in care for children. That includes speaking on their behalf at the tables they are often not invited to attend and lifting up the voices of brave youth advocates when they do speak out. Our greatest opportunity to meet all our children’ health-care needs at this moment is the careful planning of a safe, successful return to daily school. The impact on the mental, behavioural and developmental health of children and teens who are not going to school, not experiencing in-person teaching and not being with their peers, is something many of us are losing sleep over. Heightened anxiety, lack of social supports, loss of routine and social isolation are all indirect effects of school closures that can have a dramatic impact on the well-being of children and youth. A recent survey by Children’s Mental Health Ontario found one in three Ontario parents reported their

child’s mental health has deteriorated from being home from school and more than half of the parents noticed behavioural changes in their child. These ranged from drastic changes in mood, behaviour and personality, to difficulty sleeping and more. Those with pre-existing mental health issues have been hit particularly hard. The physical health of children and youth is also being negatively impacted by school closures. The meal-delivery and vaccination programs offered in schools are lifelines for many families who would otherwise struggle to access healthy food and preventive medical care. Many are spending prolonged periods of time at home without adequate supervision, resulting in both a reduction of physical activity and increase in preventable injuries. And while we have significantly underestimated the impact school clo-

sures have on children of all socioeconomic backgrounds, those who have vulnerable home situations are at particularly high risk without daily, in-person school, where teachers and school staff may be the first to identify cases of abuse or neglect. Let me briefly summarize the literature on COVID-19 and children as we know it in July 2020. Evidence is mounting that young children may be less susceptible and less likely to transmit COVID-19. There is also strong evidence that the majority of children who become infected with the virus are either asymptomatic or have only mild symptoms. However, it is important to emphasize that children (especially children with complex medical conditions) have largely been isolated, so it is possible that these data may change over time as children attend school and are in-

teracting more with peers and adults. Several countries have reopened schools without triggering a significant increase in cases. Yet, we must recognize that it will not be possible to remove all risk of infection now that COVID-19 is well established in many communities. Instead, it is time to accept this virus will be with us for some time and put in place effective strategies to ensure the safety of students, their families, teachers and school staff. This will represent a drastic shift in the mindset of a public who has, correctly, been told to stay home and avoid other people. And ultimately, ministries of education, ministries of health, public health experts, school boards, principals, teachers, parents and students are the most qualified to chart the best course for a September return to school. However, as paediatric health-care providers, we also have a role to play. We must speak up for our children and demonstrate that continuing to stay home from school has become untenable for children and youth, while providing evidence-based strategies to inform the reopening of schools for everyone’s safety. I invite you to read our new COVID-19: Updated Recommendations for School Reopening document, which addresses how schools can reopen in a way that maximizes the safety and well-being of students, teachers, school staff and families. This is a living document developed by experts from SickKids, in partnership with other Ontario hospitals and with input from a wide array of stakeholders on how we may be able to accomplish these goals. I am hopeful that with the appropriate measures in place, this year’s Back-to-School period, while certainly unique, will be a healthy, safe and fulfilling one for children and youth, H teachers, school staff and families. ■

Dr. Ronald Cohn is President and CEO of The Hospital for Sick Children (SickKids). 20 HOSPITAL NEWS AUGUST 2020

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PAEDIATRICS

Putting children at the centre of COVID recovery efforts By Emily Gruenwoldt f children are not at the centre of our country’s recovery efforts from the COVID-19 pandemic, we will have collectively failed as a nation. A costly mistake for which we will pay the price for many years to come. Since day one of this global pandemic, children have been invisible victims of COVID-19. While Canada’s kids have, thus far, largely been spared from serious illness associated with the novel coronavirus, evidence is mounting that children and youth have been – and will continue to be – the most affected by this country’s response to the pandemic. Beyond a disruption to the routine and structure in which children thrive, COVID-19 has resulted in social isolation from extended family, other adults, and peers; lengthy delays or cancellations of health assessments, diagnoses, and elective procedures; disruptions in routine

22 HOSPITAL NEWS AUGUST 2020

vaccinations and primary care. For vulnerable children and youth, a lack of access to safe and healthy foods and the security that comes with access to trusted adults outside the home. Compounding these already serious concerns will be any further disruptions or delays in a full (in-class) return to school this Fall. This ‘perfect’ storm is poised to result in potentially significant and long-lasting physical, mental, and developmental impacts for many children and to widen the gaps between them. As jurisdictions across the country (federal, provincial, territorial, local and Indigenous) grapple to define and implement a COVID recovery strategy, one thing is clear: Canada’s children are being overlooked. In order for our country to successfully rebound from the multitude of economic, social, and health impacts associated with the pandemic, children’s healthcare leaders from across the country believe all levels of government must act now to prioritize the long-term

health and wellbeing of children and youth. Putting children at the centre of our recovery efforts means prioritizing policies and investments that address children’s health and wellbeing today and into the future. Children’s Healthcare Canada and the Pediatric Chairs believe the federal government has an important leadership role to play in three areas: establishing an independent federal Commissioner for Children and Youth, investing to sustain the child health research enterprise, and advancing access to critical health services for children and youth. As a nation, Canada has been steadily dropping in global rankings over the past decade with respect to the wellbeing of our children. We currently rank 25th out of 41 OECD countries on measures of children’s health and wellbeing, according to UNICEF’s child wellbeing report card. These figures represent a significant decrease from Canada’s 12th place ranking in 2007. Fully one third of

Canada’s children do not enjoy a safe and healthy childhood. One tactic the government could employ to reverse this trend is to establish an independent federal Commissioner for Children and Youth. Such an office would fulfill a central recommendation made repeatedly to Canada by the United Nations Committee on the Rights of the Child. A Commissioner for Children and Youth would support parliamentary committees and the budget process to ensure that legislation, policies, and investments that pertain to children and youth consider their rights and well-being in order to maximize impact and avoid unintended consequences and costs. It would also work to amplify the voices of young people themselves, to ensure their opinions and experiences are better incorporated into the decisions Parliament makes on their behalf. Putting children at the centre of our recovery efforts also means investing in discovery and innovation through support for Canada’s child health research www.hospitalnews.com

PAEDIATRICS enterprise â&#x20AC;&#x201C; a sector that has suffered significant setbacks associated with the pandemic and economic downturn. Basic and translational research programs and hundreds of clinical trials to uncover life-saving or otherwise essential therapies are imminently at risk. In spite of this pandemic, children continue to be born prematurely, have rare diseases, and remain at risk for life threatening or chronic diseases. The erosion of material security during the pandemic may lead to worse birth outcomes. A child-first recovery strategy would prioritize the viability of the child health research community to ensure life changing work is not lost, for the children of today, and generations of children to come. Last but not least, it is well established that the COVID-19 pandemic has exposed and exacerbated many existing gaps in the delivery of health services to Canadians, including vulnerable children and youth. For almost fifteen weeks, most non-urgent and elective procedures came to a halt in health delivery centres serving children and youth. Routine

WHILE CANADAâ&#x20AC;&#x2122;S KIDS HAVE, THUS FAR, LARGELY BEEN SPARED FROM SERIOUS ILLNESS ASSOCIATED WITH THE NOVEL CORONAVIRUS, EVIDENCE IS MOUNTING THAT CHILDREN AND YOUTH HAVE BEEN â&#x20AC;&#x201C; AND WILL CONTINUE TO BE â&#x20AC;&#x201C; THE MOST AFFECTED BY THIS COUNTRYâ&#x20AC;&#x2122;S RESPONSE TO THE PANDEMIC. care, including some well-baby visits and childhood vaccinations were deferred. For children with special needs, most essential services delivered in the community or in the home shut down or their accessibility was significantly reduced as the result of COVID-19. The disruptions were, for the most part, an inconvenience in the short term, however many families now fear their children are experiencing an irremediable loss of functioning, and/or are observing significant physical and behavioural regressions, particularly in children with neurodevelopmental disorders.

The capacity of our health systems to thoughtfully and safely ramp up services in the days and weeks to come will be critical to reducing morbidity and ensuring health equity and positive health outcomes for Canadaâ&#x20AC;&#x2122;s children and youth for months and years to come. To support this transition, provincial and federal governments will be required to prioritize investments to secure personal protective equipment for healthcare and education workers and families, enhance testing and contact tracing, ramp up delivery of virtual services where appropriate, and facilitate tackling an ever-growing backlog

of essential physical and mental health services. Yet they â&#x20AC;&#x201C; and therefore Canadaâ&#x20AC;&#x2122;s children â&#x20AC;&#x201C; will be in competition with others for resources and priority. With news from public health officials that it could be 12-24 months before broad public health measures are relaxed in a significant way, the time to consider the impact of this pandemic on children and their families is overdue. The next several weeks and months will be defining times for all Canadians, including our children and youth. Children are by nature resilient, but the time has come to implement solutions to ensure their health and wellbeing. Canadaâ&#x20AC;&#x2122;s federal government, working in close partnership with provincial and municipal counterparts, plays an essential leadership role in the COVID recovery, and more broadly in the delivery of compassionate, safe and effective health care for all Canadians. Letâ&#x20AC;&#x2122;s not lose sight of the burden this pandemic has had on our children and youth, the sacrifices they have made to flatten the curve, and our overdue reH sponsibility to put them first. â&#x2013;

Emily Gruenwoldt is the President & CEO of Childrenâ&#x20AC;&#x2122;s Healthcare Canada and the Executive Director of the Pediatric Chairs of Canada.

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AUGUST 2020 HOSPITAL NEWS 23

FROM THE CEO’S DESK

Children are bearing the brunt of COVID-19 By Alex Munter ast year, the Ontario government challenged the health-care sector to re-organize and make care less complicated to access. The government introduced the concept of “Ontario Health Teams” (OHT) – to build a connected healthcare system centred on patients, families and caregivers. These teams are to support both the patients and healthcare providers, delivering a coordinated continuum of care in designated regions. The goal of this new and innovative system is to provide faster ac-

24 HOSPITAL NEWS AUGUST 2020

cess to better quality care while making it easier for families to move from one provider to the next. Children and youth are not tiny adults. They have unique needs and their lives are very different than their parents, teachers, and child-care workers. Understanding this, child and youth health organizations and physicians in the Champlain region of Eastern Ontario came together to organize services around their reality. Called an “innovative model” by the Ministry, eastern Ontario’s Kids Come First Health Team has tailored the OHT

concept for kids. Health Minister Christine Elliott said, “As we reviewed the many excellent applications to become an Ontario Health Team, it became clear to us that there are some proposals like Kids Come First that provide invaluable services for specific patient populations that should not be contained within a single team.” Partnered with family and youth, the Kids Come First Health Team includes over 60 organizations, supported by 1,100 pediatric physicians. Since the beginning of the COVID-19 outbreak, we have been able to mobi-

lize our services to serve children and youth infected by the virus and, just as important, support families affected by it. When COVID-19 arrived in Canada, the Kids Come First Health Team saw the possibility of children bearing the brunt of Canada’s response. Amidst a pandemic like this, are kids supposed to suddenly stop being kids? To just stop growing and developing? In the life of a child, every day counts. The difficult choices we had to make around provision of health care disproportionally affect kids’ developing www.hospitalnews.com

FROM THE CEO’S DESK brains, growing bodies, and wellness. We cannot afford for young people in Ontario to be collateral damage, especially since COVID-19 will be with us for some time. The early years are crucial to a child’s development, and not something we can put on pause. How do you tell a family that their occupational therapy visits to teach toilet training or behaviour therapy sessions to teach social skills are not essential? Investing in pediatric health not only provides personal benefit when kids are kids but, also, long-term economic benefit to the province when our children grow into healthy, thriving adults. During the COVID-19 pandemic, health-care providers have been forced to reduce services and focus on ‘essential and urgent’ care. As many services were temporarily suspended, seemingly overnight, the Kids Come First Health Team mobilized to support children and their families. With the member organi-

zations’ strong foundation of services already established, the Kids Come First Health Team was able to adapt to the changing needs of our patients. The Kids Come First Health Team acted quickly and effectively to address some key gaps. We set up immunization clinics for scheduled vaccinations of babies and toddlers under the age of two. These clinics were centered around families who were not able to obtain their immunizations through family physicians or community pediatricians. Our goal was to prevent a legacy of post-COVID-19 outbreaks of preventable disease. We established an isolation centre for vulnerable youth at risk of homelessness, aged 16 – 21, to provide a safe space to self-isolate, recover or await COVID-19 test results. In addition, we set up a unique child and youth protection clinic for high-risk children who did not have primary-care providers within their foster homes.

We provided in-home nursing assessments and in-home respite services for families of children and youth with medically complex or palliative needs. This included emergency respite to family caregivers, giving them a temporary break because caring for a child with special needs or complex care needs is unimaginably tough at the best of times and even harder when community support options are forced to temporarily close. We delivered expertise and support for congregate living and care facilities – we could not afford to have these specialized, limited group homes shut down as part of the COVID-19 response, potentially leaving youth with disabilities no place to live. This response was akin to how hospitals stepped up to help seniors in long-term care homes. As Ottawa Public Health has stated, the prolonged school shutdown

has also had big impacts on the lives of many children – their development, emotional well-being, physical and mental health. For some, these impacts have even included losing access to nutrition and losing their safe refuge from difficult or dangerous home situations. Kids Come First stands ready to work with families, teachers, school boards, and others to help support a safe return to school. COVID-19 is not going anywhere fast, so the Kids Come First Health Team is here for families when, where, and how they need us most. We exist to connect child and youth health services for better quality, faster access and easier transitions. And, we are here to support other Ontario Health Teams by bringing pediatric expertise to the table to ensure our new system works for kids. We’ve got this. Young people – and their parents and caregivers – are H counting on us. ■

Alex Munter is President and CEO of CHEO, a pediatric health and research centre in Ottawa, one of the 61 organizational partners in the Kids Come First Health Team.

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PAEDIATRICS

New video virtual care project enhances care for Ontario’s tiniest patients By Julie Dowdie and Jessica Marangos hen Katie and Jeff Lavelle’s newborn son, Edward, needed to be treated for complications arising shortly after his birth, the world-class team of paediatric experts assessing him were simultaneously right by his bedside and more than 40 kilometres away. Little Edward benefited from the launch of a new Kids Health Alliance (KHA) virtual care project that allows the care team at Markham Stouffville Hospital’s (MSH) Neonatal Intensive Care Unit (NICU) to consult experts at The Hospital for Sick Children (SickKids) with the added use of video. The project introduces video capabilities between consulting physicians and nurses in MSH’s NICU and the SickKids Acute Care Transport Service (ACTS) team. With specialized training and equipment, the SickKids ACTS team brings the expertise of newborn and paediatric intensive care as well as transport medicine to community hospitals. Currently in Ontario, 49 NICUs access the province’s Neonatal Consult, Transfer and Transport program to seek input from paediatric and neonatal medical specialists. Up until now, this program has been accessed exclusively over the phone. “Adding video capabilities to this process provides eyes on the baby, significantly improving the SickKids team’s ability to determine if the baby needs to be transferred and what measures can be taken to keep the baby stable until the transport team arrives. The SickKids team is also able to collaborate better with MSH to identify and avoid unnecessary transfers,” explains Larissa Smit, Interim Executive Director at KHA. Following the video consult with SickKids, Edward did not need to be transferred and was able to stay at

Katie Lavelle with husband Jeff (left) and their newborn son Edward.

MSH. For Katie and Jeff, having those “extra sets of eyes” to evaluate their son added an additional layer of reassurance during a very stressful time. “We already were so confident in the health-care team at MSH and had chosen to have our baby here because of the hospital’s great reputation. However, it was also such a relief to know that MSH was able to take Edward’s care a step further and consult with other specialists,” Katie says. “Every second counts with these tiny patients,” adds Jo-anne Marr, President and CEO of MSH. “Participating in this KHA project to add the ability to see the baby in real time and monitor how they are doing will improve their health outcomes and allow us to deliver enhanced quality care close to home for the entire family.” “Access to virtual care is more important than ever. In a matter of

weeks, virtual care has become a primary method of health care delivery,” notes Dr. Ronald Cohn, Chair of the KHA Board and President and CEO of SickKids. “We are excited to launch this initiative with Markham Stouffville Hospital that will provide timely advice between clinicians and a better experience for patients and their families.” Kids Health Alliance, founded in 2017 by SickKids, Holland Bloorview Kids Rehabilitation Hospital (Holland Bloorview) and CHEO, is a not-forprofit network of health-care organizations that collaborate to make tangible improvements in care for children and youth. The Network currently includes the three founding specialty paediatric hospitals and six community hospitals. In addition to MSH, this includes Humber River Hospital, Michael Garron Hospital, Orillia Soldiers’ Memorial Hospital, Pembroke

Regional Hospital and Southlake Regional Health Centre. In the first month of the project, eight calls with the added use of video occurred for five different babies, including Edward. Through KHA, the project teams at MSH and SickKids will participate in an evaluation of the project to measure outcomes, including clinician’s perceptions about the benefits of adding video, avoidance of unnecessary transfers and overall experience. KHA will also monitor if the added use of video translates to more ‘advice only’ calls that allow the baby to stay at MSH, resulting in financial benefits to the health-care system due to a reduction in transfers. Based on the evaluation results, KHA plans to expand the project to the other community hospital partners. For more information about KHA, H visit www.kidshealthalliance.ca. ■

Julie Dowdie is a Senior Communications Specialist at Markham Stouffville Hospital and Jessica Marangos is Lead, Strategy Implementation at Kids Health Alliance. 26 HOSPITAL NEWS AUGUST 2020

www.hospitalnews.com

PAEDIATRICS

Solutions for Kids in Pain (SKIP):

Changing how we

manage

children’s pain ll children experience pain. Two-thirds of children in hospital experience procedures with no pain management, one in five children will develop chronic pain after surgery, and upwards of 3 million Canadian children will experience chronic pain before adulthood. As recently as the 1970s and 1980s it was believed that babies, especially premature babies, didn’t feel pain. We’ve come a long way, but we’re still failing children when it comes to pain. Fortunately, Canada is a world leader in research about children’s pain and there are many simple, evidence-based and cost effective things patients, parents, caregivers, and health professionals can do to help children have less pain – IF they know about them. There is a well-established body of existing research on children’s pain, and a lot of what we know from this research is not being used in the clinical setting. The goal of SKIP is to get that information out there. For example, inadequate pain management is reported for children during routine vaccinations and medical procedures, after surgery, and in the context of chronic pain and disease. We consider the three Ps of pain management: physical, psychological, and pharmacological. Evidence-based strategies for babies include breastfeeding, skinto-skin contact, and sucrose (sugar water) during painful procedures. For

“Better pain management in children means healthier Canadians for life.”

older children, strategies include distraction, deep breathing, relaxation, and numbing cream for vaccinations. We think of needles as “Quick! Get it done!” But if we restrain a child, what happens next time? Sometimes a parent knows about a new pain management practice, but is confronted by a resistant health professional. Sometimes it’s the health professional who has the best information, but works within an organization that lacks the tools and resources to implement it. People who work with children love children – no one wants to see them suffer, but many don’t know there’s another way. Health professionals often lack training in pain management, and sometimes pain management isn’t part of the culture of an institution. Part of what we need to overcome is the idea that pain isn’t a big deal. We know from decades of research that poorly managed pain, especially early in life, has a negative impact on children’s brains and bodies. They are at risk of experiencing more pain as adults, avoiding necessary health

care like vaccinations, and developing more complex problems with pain and substance misuse. It’s about helping people realize that there are significant and long-term consequences to not addressing pain, and there are simple things you can do to help children that don’t cost anything or take extra time. We often think that health professionals are constantly accessing and implementing new research. But we know it can take up to 17 years for new research to reach the patients and caregivers who will benefit from it! As shared by Isabel Jordan, a SKIP Patient Partner and parent of a youth with a rare genetic disease, “We had all these incredibly problematic experiences with procedural pain. In the moment, we were given no options. I now know there are evidence-based solutions and things could have been done differently. The thought that all this research is happening and it’s just sitting there on a shelf makes me angry! I know other families are going through this. We need to change clinical practice. Even when parents and caregivers know the best ways to manage their child’s pain, it’s vulnerable and scary to go up against someone with power and say, “I know how to do this better.” The SKIP approach is a new way to mobilize knowledge in healthcare. SKIP facilitates collaboration between patients, caregivers, researchers,

health professionals, institutions, and partners like start-ups and government in a synergistic way. Together, we drive change in organizations and throughout the healthcare system. When you have a patient or caregiver who feels empowered, health professionals armed with information, and health centres prioritizing children’s pain, outcomes are improved. SKIP works to empower patients and caregivers, ensures health professionals have access to the best information, supports healthcare administrators in creating environments that support change, and helps the healthcare system embrace new ways of managing children’s pain. SKIP is co-led by Dr. Christine Chambers, SKIP’s Scientific Director, and Doug Maynard, SKIP’s Knowledge User Director who work closely with SKIP’s Assistant Scientific Director, Dr. Katie Birnie, and the rest of the SKIP team across Canada. SKIP has four regional hubs (IWK Health Centre, Children’s Healthcare Canada, The Hospital for Sick Children, Stollery Children’s Hospital) and three affiliates (BC Children’s Hospital, Alberta Children’s Hospital, Children’s Hospital Shared Health Manitoba). Together, we can push boundaries and think outside the box of traditional healthcare. SKIP’s work will ultimately help children and families as better pain management leads to healthier H Canadians. ■

SKIP is funded by the Networks of Centres of Excellence (NCE), based at Dalhousie University and co-led by Children’s Healthcare Canada. Visit www.kidsinpain.ca for more information or follow us @kidsinpain. www.hospitalnews.com

AUGUST 2020 HOSPITAL NEWS 27

VIRTUAL CARE

New virtual clinic

streamlines care for COVID-19 patients By Erinor Jacob-Levine eceiving a positive COVID-19 test result can be both scary and overwhelming due to the potentially serious and largely unknown consequences of the virus. To better support those who have been diagnosed with COVID-19, six physicians at London Health Sciences Centre (LHSC) have developed a new care pathway to identify, triage, monitor, and manage the potential complications of the disease through a new virtual clinic. The LHSC Urgent COVID-19 Care Clinic is caring for patients referred from the Middlesex-London Health Unit, Emergency Department, and family practitioners, as well as patients discharged from inpatient services. “We want to see all patients in London with COVID-19 as soon as possible after their diagnosis. This will help us identify those at high risk for complications so that we can arrange home monitoring of oxygen levels,” explains Dr. Erin Spicer, a general internist at LHSC and one of the creators of the clinic. Dr. Spicer describes how research is showing that patients with COVID-19 may not seek care until it’s too late because the symptoms of low oxygen levels may not be noticeable early in this disease. “These patients can experience hypoxia – low oxygen levels – without the typical warning signs such as shortness of breath,” Dr. Spicer says, “by the time they do exhibit signs and get help, they can be at a critical stage in the disease.” The clinic is working with patients to prevent this deterioration by giving them an algorithm they can use to self-monitor their health with physician support. If a patient is over the age of 40 or has a pre-existing chronic condition that puts them in a higher risk category for hypoxia, they are sent a pulse oximeter immediately. The following day during their vir-

Dr. Marko Mrkobrada, one of the physicians who helped create the Urgent COVID-19 Care Clinic at LHSC shows an example of an oximeter that is sent to high risk patients to help them self-monitor their oxygen levels.

THE URGENT COVID-19 CARE CLINIC IS PROVIDING RAPID TELEPHONE ASSESSMENTS AND HOME MONITORING OF OXYGEN LEVELS FOR PATIENTS DIAGNOSED WITH COVID-19 tual consult, the physician explains how to monitor symptoms using an algorithm, how to use the pulse oximeter and when to call the clinic, the on-call physician, or an ambulance. “We’ve created a monitoring algorithm for the patient to follow which helps them determine when they need to contact the clinic,” explains Dr. Devlin, an infectious disease specialist

and co-creator of the clinic. Patients can reach the clinic either by phone, email or more urgently through the pager system which is answered by the clinic’s on-call physician. There is also an intake process for patients from the clinic who need to be admitted. Patients are admitted directly to their designated bed with the appropriate personal protective equip-

ment when they arrive at the hospital thereby avoiding the Emergency Department and decreasing the risk of exposure to healthcare providers and other patients. The clinic concept was developed by Drs. Marko Mrkobrada, Michael Nicholson, Erin Spicer and Megan Devlin. They, along with Drs. Inderdeep Dhaliwal and Jaclyn Ernst, plan to follow patients over the next year, both virtually and in person, to ensure they have the support they need. Based on patients’ needs, the clinic has developed subspecialists referral pathways to Psychology, Otolaryngology, Cardiology, and Neurology. Future collaborations are planned with Physiotherapy and dieticians. The virtual clinic is overseen by the Department of Medicine and will run as a continuous quality improvement initiative. It will undergo multiple plan-do-study-act (PDSA) cycles to ensure the process is as efficient and easy as possible for patients, while still producing meaningful data needed by the physician team to inform an appropriate care response. “We are excited to collaborate with our physicians and the Middlesex-London Health Unit to provide support and care to this patient population,” says Ann Turcotte, Director, Department of Medicine at University Hospital, LHSC. “We are very happy our virtual care program is helping COVID-19 patients during this pandemic.” Turcotte is responsible for overseeing the administrative implementation and on-going progress of this initiative. In just over two months, the clinic has seen 82 new patients. Of those, 63 per cent meet the criteria for requiring monitoring of their oxygen levels at home. The clinic plans to expand capacity over the next several months in preparation for a potential second wave. This quality initiative is helping ensure patients get the care they need, H when and where they need it. ■

Erinor Jacob-Levine is a Communications Consultant at London Health Sciences Centre. 28 HOSPITAL NEWS AUGUST 2020

www.hospitalnews.com

VIRTUAL CARE

Adapting the way we deliver care safely during a pandemic By Amy Richardson ommunity is everything to Aurelia Leishman. As a widow, she places a lot of value on her independence, on keeping active and staying connected to those around her. On any given day, a brave and cheerful Aurelia can be seen around her neighborhood saying hello to friends or walking her Yorkie-Poodle mix. But earlier this year she had to change her routine. In early March, Aurelia had a successful total knee replacement surgery at Mackenzie Health, right before scheduled surgeries were put on hold because of the pandemic. “I’ve spent a lot of time at Mackenzie Health, it’s a second home for me,” explains Aurelia. Her community hospital is a place she trusts. “This is my second knee replacement, so I actually knew

what to expect and I knew the team in the hospital would take great care of me. But it was different this time with COVID-19, I admit I was a bit scared.” After surgery, Aurelia spent time in the hospital so that her care team could help her regain mobility and she could go home safely. To ensure that patients like Aurelia continue to receive the care they need even after they leave the hospital during the pandemic, Mackenzie Health, in partnership with SE Health turned to virtual visits. After being discharged from the hospital, Aurelia was one of the first patients at SE Health’s Rehab Clinic to have a virtual visit with a physiotherapist. “Our virtual care started during the first call,” says Anna Zhao, the physiotherapist who treated Aurelia. Anna has been a physiotherapist for close to 15 years, and even had her own experience with total knee re-

placement as a caregiver to her mother last fall. Given Anna’s experience and knowledge, she approached Aurelia’s care holistically from the very start. “Virtual care can be hard when you haven’t met the patient yet,” says Anna. “But after learning more about her life and finding out how communicative she was, I knew that connecting over the phone would make the most sense for her.” “It was great, Anna called me right away. I could call anytime, I felt really supported,” says Aurelia. For her, the trust she had in Mackenzie Health naturally extended to SE Health’s Rehab Clinic as she continued her recovery journey from hospital to home. “During her virtual visits, Aurelia and I would talk about her knee and how to prevent falls. But we would also talk about her life,” recalls Anna. “And during those talks I was able to

• Emergency department triage. • Virtual on-call and physician rounds. • Enhanced physician access for long-term care homes. • Outpatient and specialty clinic virtualization.

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give her guidance on walking her dog safely, being careful on the stairs and beginning to drive again. I was able to treat her as a whole person.” With restrictions gradually being lifted, Aurelia is now able to see Anna in person at the SE Health Rehab Clinic. Even though they had in-person treatment sessions, their most memorable visit was virtual – when Aurelia bent her knee to almost 100 degrees. “Yes, and we celebrated through the phone,” Anna remembers, laughing fondly. Thanks to the partnership between the Mackenzie Health and SE Health’s Rehab Clinic, Aurelia was able to stay on track and recover from her surgery during COVID-19. As she returns to her normal activities, she credits the teams at the hospital and at the Rehab Clinic for helping her to return to her community as an active member. Continued on page 31

VIRTUAL CARE

Better analytics, virtual visits help enhance diabetes care ELIMINATING WAIT TIMES

By Jessica Rudd s a registered nurse who works with residents with dementia at a long-term care home in Edmonton Alberta, Karen Pliska, 55, is acutely aware of the risks posed by the COVID-19 pandemic to those in her care, and to herself. Not only is she working on the front lines, she must manage her own chronic condition, Type 1 diabetes, which puts her at greater risk of more severe symptoms if she were to contract COVID-19. Like millions of Canadians living with chronic health conditions, Pliska has had to adapt to new physical distancing protocols over the past several months that put a temporary halt to in-person visits with her doctor and the medical team at her diabetes clinic. But Pliska is among the growing swell of patients who have been able to harness the power of technology, remote monitoring tools, and virtual visits to not only continue getting the care they require, but also to improve the overall patient experience. Pliska, who has lived with diabetes since she was three, began using the world’s first self-adjusting insulin pump in March, just as the COVID-19 pandemic was really taking hold in Canada and the country began shutting down. At the same time, she started using Medtronic’s CareLinkTM remote monitoring software. The web-based program collects data directly from her insulin pump and continuous glucose monitoring system. It generates detailed reports that can be discussed during visits with her healthcare practitioner and is used to develop care plans. “It’s been a godsend that I’m still being looked after and have help available if I need it, especially if I run into problems,” says Pliska.

The CareLink data from an anonymous patient that shows how the patient’s “time-in-range” improved.

A SURGE IN ADOPTION

Like many virtual tools in healthcare experiencing a surge in use since the onset of the pandemic, CareLink has been on the market for years. As diabetes clinics across Canada were forced to shut down in-person visits, however, the ability to effectively and efficiently embed virtual care in the patient pathway became a priority. And because Alberta has a fully integrated health system, it was able to expedite adoption by reviewing the software for privacy and security compliance centrally, rather than every hospital having to do this separately. As a patient, Pliska says the remote monitoring and support available through CareLink provide her a feeling of security, even if she’s travelling or away from home. “I feel very safe if something did happen. Medtronic has a 24-hour

phone line with technicians available to log in and see what I’m talking about. It makes me feel safe that if I’m not at home with my regular physician there will still be someone there for me and it will prevent me from going to a hospital or an ER somewhere else.” The vast majority of patients at the Diabetes Hypertension and Cholesterol Centre in Calgary have embraced virtual visits and are using CareLink to keep tabs on their diabetes, says Nurse Clinician Jody Wiebe. While there is often a learning curve for patients to figure out how to use the technology and upload their data, training and education are available to help users overcome any challenges they may be having. “When we look back to a couple of years ago about half our patients were using CareLink. That’s now up to about 80 per cent or 90 per cent,” Wiebe says.

Most patients are ultimately convinced of the value of using the CareLink software by the detailed reports it generates on everything from blood-sugar levels, time in range, glucose values and dozens of other data points. The reports – which can provide snapshots of a single day or months at a time – help patients better understand their diabetes and how to manage it, which is especially important for people who might not get physical symptoms when their glucose levels go too high or too low. “I think it puts patients on a more equal footing with their healthcare provider. It’s really increased the learning because patients are taking more time to look at their reports and understand the data,” Wiebe says. Virtual visits have also increased convenience for patients by decreasing travel time and costs, particularly those who live outside Calgary. “We have a lot of patients who have concerns about coming in for face-toface visits. For them to be able to be in an environment that’s comfortable for them is important,” Wiebe says. Joyce Kunikoff, a Registered Nurse and diabetes educator at the Grey Nuns Centre for Diabetes in Edmonton, says CareLink and telephone consultations with patients have had another added benefit – eliminating wait times. “It’s a lot quicker when we have scheduled calls. Our wait times are completely gone. We don’t have a lot of people sitting in a waiting room, which is better for patients and helps relieve pressure on staff,” she says. Kunikoff, who has Type 1 diabetes herself, says she sees an ongoing role for using more virtual care tools in the future. “I would say we will likely stick with it. We’ve always done a lot of phone appointments, so we were able to make a fairly smooth transition to this model,” she says. ■ H

Jessica Rudd is Health Systems Strategies & Government Affairs Director for the Western Provinces at Medtronic Canada. 30 HOSPITAL NEWS AUGUST 2020

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VIRTUAL CARE

Bringing virtual care to COVID-19 patients By Jordan Benadiba OVID-19 has brought about an unprecedented opportunity to optimize our health system and redesign care using virtual and digital health tools. One such example of virtual care innovation is COVIDCare@Home, a virtual care program in the Toronto area providing real-time support to primary care providers as they care for patients recovering from COVID-19 at home. The program also provides direct support to COVID-19 patients through virtual visits with a multidisciplinary team at Women’s College Hospital (WCH). “We know that most symptomatic, yet stable COVID-19 patients need to monitor their symptoms at home. We also know that this is a difficult time for them, with many financial, social and mental health pressures. COVIDCare@Home allows us to ensure continuity and access to care,” says Elaine Goulbourne, director of clinical resources & performance and clinical director of primary care & Peter Gilgan Centre for Women’s Cancers at WCH. Since April, the program has seen over 250 patients and conducted over 1200 visits. As a result of the virtual visits and remote monitoring provided by COVIDCare@Home, hospitalization rates for patients enrolled in the program have been low, with only a few patients needing emergency care. What differentiates COVIDCare@ Home is its emphasis on providing a comprehensive family medicine ap-

Dr. Agarwal demonstrating how to us a device that monitors oxygen levels during a virtual visit with a patient. proach to patients with COVID-19 while building on their relationship with their existing primary care provider. “Our program is leveraging technology, like video visits and remote monitoring devices, to rethink how care is delivered and create a model that supports patients, caregivers and their primary care team during the COVID-19 pandemic,” explains Dr. Payal Agarwal, a WCH family physician, the medical director of COVIDCare@Home and an digital health researcher. Applying a collaborative and multidisciplinary approach, the COVIDCare@Home team includes staff family physicians, residents, nurses, social workers, pharmacists, medical secretaries, general internal medicine and mental health specialists. “We have leveraged existing partnerships with University Health Network, Sinai Health System, SCOPE and the Department of Family and

Community Medicine at the University of Toronto to bring this program to fruition,” Goulbourne adds. Should a patient have more complex needs requiring in-person care, they are seen by WCH’s Acute Ambulatory Care Unit (AACU). This ensures that patients receive handson care to address either existing health needs or complications as a result of COVID-19, while avoiding the emergency department. This approach combining virtual care with just-in-time in-person treatment has enhanced patient outcomes. As the program progresses, some key learnings have been gained. “Team based care, including mental health and social work supports have been critical. For instance, patients have needed assistance with food delivery, applying for government funding programs, finding a primary care provider and brief therapy for anxiety,” says Agarwal.

Continued from page 29

Adapting the way we deliver care “Stories like Aurelia’s are examples of how working together can have positive outcomes for patients,” said Richard Tam, Executive Vice President and Chief Administrative Officer at Mackenzie Health. “Keeping our patients and staff safe while delivering the ultimate in care during the pandemic has been our top priority at Mackenzie Health and the investments we made in smart technology

have helped us deliver that care in innovative ways.” The professionals at SE Health’s Rehab Clinic have been caring for Mackenzie Health patients for years, making sure that they have the supports they need to recover as best as possible and resume their regular activities when back in the community. “Our long-time partnership is one that has been built on trust, collaboration, flexibility, seizing opportuni-

Amy Richardson is a Marketing and Communications Specialist at SE Health. www.hospitalnews.com

ties and most of all, ensuring that the patient and provider needs and experiences are at the forefront of what we do together,” says Shelby Fisch, Vice President, Acute Operations, SE Health. “Total Joint Replacements are one of our most recent collaborations. Together we are optimizing outcomes along the patients’ entire care journey through innovative and personalized care when and where it H counts.” ■

Social determinants of health are clearly playing a significant role in the course of the pandemic and impacting a person’s health outcomes. “We serve a diverse patient population, with many patients from communities who traditionally face barriers accessing care. Many have been facing significant financial pressure, are living in cramped housing or are facing language barriers By providing patients with a full spectrum of care, we are better able to respond to their needs and escalate care should their health deteriorate,” Agarwal explains. COVIDCare@Home has also seen a positive response to delivering a pulse oximeter, which allows remote monitoring of a patient’s oxygen levels. This device has been particularly helpful for patients living with multiple chronic conditions. Prior to joining the program, many patients reported feeling alone and had difficulty accessing care or getting answers. Regular check ins, remote monitoring and additional supports have provided a sense of relief. “We recently had a patient who works in a congregate living facility and lives with asthma. Upon reflection, he told us that entering the program was pivotal in his recovery and that his daily visits via Zoom and the ability to track his oxygen levels gave him reassurance. Another patient shared that having the number for the resident-on-call let them know they weren’t alone even while self-isolating,” Agarwal says. COVIDCare@Home is a part of the hospital’s Women’s Virtual initiative, which is transforming the organization into Canada’s first virtual hospital. “We know that there will be an on-going need for this program throughout 2020, particularly for those at a higher risk of contracting COVID-19. As that need lessens overtime, we are going to explore how this model can support other patient populations, including those with multiple chronic conditions and seniors under our Aging at Home Program,” Goulbourne explained. To learn more about COVIDCare@ H Home please visit: covidcareathome.ca ■ Jordan Benadiba works in communications at Women’s College Hospital. AUGUST 2020 HOSPITAL NEWS 31

VIRTUAL CARE Dr. Navika Limaye has been able to see many of her patients through virtual care through-out the pandemic.

Virtual health care:

A win-win for patients and care providers By Jennifer Stranges n semi-retirement, 65-yearold Norma keeps busy with a roster of hobbies including choir, Barbershop quartet and Scottish country dancing. But when COVID-19 shut down the province, Norma, a patient at St. Joseph’s Health Centre’s family health team, had no option but to slow down. During this time, Norma, who lives with bipolar disorder, experienced a decline in her mental health. And if it were not for virtual health care – which was swiftly made available in Ontario due to the pandemic – Norma’s family physician may not have had the chance to catch the signs and adjust her treatment. “The virtual visits were fantastic because we were in touch on the phone on a weekly basis,” says Norma of her interactions with her family physician, Dr. Navika Limaye. “I would keep track of changes in how I was feeling and was able to report back to her.” Dr. Limaye, who is the chief of family medicine at St. Joseph’s, says the weekly check-ins would not have been possible in-person, and the frequency of their phone appointments helped her monitor Norma’s symptoms.

“When someone with bipolar disorder decompensates, it takes a lot to get them back on track. They can end up in a crisis unit at the hospital. The phone appointments allowed us to catch the signs and prevent the decompensation.” Norma is feeling great these days, and is crocheting, reading and having meaningful conversations with friends. She looks forward to getting back to her routine and hobbies once the pandemic is contained, but hopes virtual care is here to stay. “I appreciated those phone calls so much.” As COVID-19 forced non-emergency clinics and medical services to close across the country, many health care providers went online to support their patients. A recent poll by the Canadian Medical Association (CMA) showed Canadians would like to see virtual care options continued after the COVID-19 crisis subsides. They also want to see it improved and expanded. Nearly 40 per cent of Canadians says moving forward, they would like their first point of contact with a doctor to be a virtual visit rather than in-person.

One major draw for virtual care is that it provides patients with flexibility, so they are not planning their day around their medical appointment. In the CMA report, 60 per cent of Canadians indicated a virtual visit as a first point of contact with a doctor would improve convenience for patients. “It’s a great option for patients so they don’t have to go through angst of organizing child care or taking time off work to go to their doctor’s office,” says Dr. Limaye. “It’s also great for patients with circumstances that could make it difficult to come to the doctor’s office.” Norma says it takes her nearly two hours to travel to the hospital for an appointment, and she appreciated the convenience of her telephone appointments. The possibility of being late for in-person appointments has previously brought her a great deal of stress, she added, and avoiding stress during such a significant time in her care was a relief. “While video appointments are an innovative solution to care during this pandemic, telephone care is not new to family physicians,” says Dr. Limaye. She noted that such calls were usually squeezed between in-person appoint-

ments, or done at the end of a doctor’s work day or on their lunch. But the launch of virtual care has made telephone care more structured and measurable, and along with video appointments, has allowed care providers the opportunity to check in on their patients more frequently and to not have their schedules impacted by the nuances of in-person visits such as no-shows, late shows or patients forgetting to bring their medications to the appointment. Telephone appointments are a great virtual visit option for patients who may not be tech-savvy and have difficulty managing video call programs. Dr. Limaye says that in-person care is still very important, and different care options are appropriate at different times. “Sometimes a phone call is adequate, but sometimes it isn’t,” she says. She believes investment in virtual health care will have a domino effect on the health care system. “A little bit of investment in virtual care can have a huge pay off in terms of reducing hospital admissions to emergency departments or crisis H units.” ■

Jennifer Stranges is a communications advisor at Unity Health Toronto. 32 HOSPITAL NEWS AUGUST 2020

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SAFE MEDICATION

Deprescribing: When less is more By Jacob Poirier, Victoria Bugaj, and Certina Ho hen providing patient care, we often think of diagnosing a medical condition and providing treatment in the form of medications. What we may not consider as frequently is that prescribed medications may not necessarily need to be taken indefinitely. In fact, as health care practitioners, we must be judicious in our assessment of efficacy, safety, and necessity of medication therapy our patients are receiving.

POLYPHARMACY

The emphasis on the use of drug therapy is a potential contributing factor to polypharmacy, which is defined as concurrent use of five or more medications, including both prescription and non-prescription medications. As patients age, they may be diagnosed with an increasing number of chronic medical conditions and ailments in tandem with an increase in medication use. For example, in 2016, the Canadian Institute for Health Information (CIHI) reported that approximately 35 per cent of older adults over the age of 65 took five or more chronic medications. This increased medication use is not only financially costly for patients as well as the private and public drug benefit programs, but also dramatically increases the potential risks of adverse drug reactions and/or drug-drug interactions. Additionally, adherence to medication therapies is likely inversely related to the number of medications a patient is taking. These possible health risks and economic burdens may be mitigated by continuous efforts to monitor, assess, and perhaps even simplify medication regimens when necessary and appropriate. Oftentimes patients may receive medication therapy from multiple prescribers or fill prescriptions at dif-

ferent pharmacies, which may hamper our ability to recognize and rectify occurrences of polypharmacy or unnecessary medication use. Performing a comprehensive medication review at a community pharmacy or medication reconciliation upon hospital admission, transfer, and discharge are great opportunities for both the patient and healthcare practitioners to gain a clear picture of the patient’s best possible medication history prior to any further addition or adjustment to the patient’s existing medication regimens. Medication reviews can assist health care providers to deduce if there are redundant medications – for example, duplicate therapy, when medications are no longer indicated, or if the risks of remaining on the medication(s) may outweigh the long-term benefits of discontinuing therapy, etc. When any of these criteria are met, deprescribing of the identified medication(s) may need to be considered.

DEPRESCRIBING

Deprescribing is defined as the planned process of reducing or stopping medications that may no longer be of benefit or that may be causing harm to the patient, with the ultimate goal of reducing medication burden and improving quality of life. For instance, medications that may be appropriate and considered for deprescribing include proton pump inhibitors (PPIs), antihyperglycemics, antipsychotics, benzodiazepine receptor agonists (also known as hypnotics or sedatives), just to name a few. There have been several clinical trials examining deprescribing efforts in Canada. For example, the EMPOWER trial demonstrated that providing patients with educational pamphlets on benzodiazepine use increased pa-

THE EMPHASIS ON THE USE OF DRUG THERAPY IS A POTENTIAL CONTRIBUTING FACTOR TO POLYPHARMACY, WHICH IS DEFINED AS CONCURRENT USE OF FIVE OR MORE MEDICATIONS, INCLUDING BOTH PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS. AS PATIENTS AGE, THEY MAY BE DIAGNOSED tient knowledge on the risks and benefits of these medications, as well as discussions with physicians and/or pharmacists about the information, followed by a discontinuation of inappropriate benzodiazepine use among chronic users. As a follow-up to the EMPOWER trial, the D-PRESCRIBE trial further demonstrated that when pharmacists provided prescribers with evidence-based recommendations regarding the potential harms associated with sedative hypnotics, oral sulfonylureas, non-steroidal anti-inflammatory drugs (NSAIDs), and first-generation antihistamines, there was a greater reduction in prescriptions filled for inappropriate medications by patients.

their circle of care, and with a mutual understanding of meeting patient-driven care goals. If multiple medications are identified as candidates for deprescribing, it is important to discontinue one medication at a time. This will allow for continual assessment and monitoring throughout the deprescribing process to manage any adverse effects which may arise. Following successful discontinuation of the first therapy, the tapering process of the subsequent medication may begin. Pharmacists are in a unique position to utilize this patient-provider collaboration to identify opportunities for deprescribing and offer frequent monitoring of patient’s medication therapy.

ROLE OF PHARMACISTS RESOURCES FOR IN DEPRESCRIBING DEPRESCRIBING It comes without surprise that pharmacists, as one of the healthcare providers most frequently encountered by a patient in the health system, are well equipped to assist in deprescribing. As medication experts, pharmacists are well positioned to perform comprehensive medication reviews and identify medications which may be candidates for deprescribing. The decision to deprescribe should always be done in partnership with the patient and healthcare practitioners involved in

As the deprescribing movement grows, an increasing number of tools are becoming available to healthcare providers. For example, the Bruyère Research Institute (Ottawa) launched www.deprescribing.org which has many useful resources to aid in the deprescribing process. Such resources include deprescribing algorithms and schedules for healthcare providers, information pamphlets, case reports, and a publications library illustrating the benefits of H deprescribing initiatives. ■

Jacob Poirier and Victoria Bugaj are PharmD Students at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and Leslie Dan Faculty of Pharmacy, University of Toronto. www.hospitalnews.com

AUGUST 2020 HOSPITAL NEWS 33

LONG-TERM CARE NEWS

Winners

of the AGE-WELL National Impact Challenge By Annie Webb and Margaret Polanyi he need has never been greater for technologies and services that benefit older Canadians and their caregivers – so it’s no surprise that the 2020 AGE-WELL National Impact Challenge attracted a lot of attention. The national competition recognizes top start-ups and supports entrepreneurship in Canada’s technology and aging sector. Finalists are challenged to explain how their technology-based solution can positively impact seniors or their caregivers. The first two competitions in the three-part series played out virtually in June and July, with five finalists competing at each event for $20,000 in cash, as well as in-kind prizes. And the winners are…

ABLE INNOVATIONS

Able Innovations won the Toronto regional competition, held on July 9, for its “effortless” automated patient-transfer technology. Founder and CEO Jayiesh Singh told the judges that the DELTA Platform allows a single caregiver to transfer a person in a safe and dignified manner. “Our device is mobile, compact and easy to use,” says Singh, who first encountered the challenges around patient transfer while volunteering in long-term care homes in his youth. “Current methods of transfer require two or more caregivers in a process that is time-consuming and physically demanding. It can also lead to transfer-related injuries, both for staff and patients,” adds Singh. Able Innovations’ smart technology uses compact platforms to safely roll underneath individuals being transferred. An AGE-WELL-supported

34 HOSPITAL NEWS AUGUST 2020

Michael Cullen (left) of Novalte and Alex Roberts (right) of eNable Analytics. The two companies tied for first-place in the Atlantic Canada competition.

THE NATIONAL COMPETITION RECOGNIZES TOP START-UPS AND SUPPORTS ENTREPRENEURSHIP IN CANADA’S TECHNOLOGY AND AGING SECTOR. study done with Bruyère Research Institute and Carleton University has helped to perfect the system and demonstrate its safety and efficacy. “Right now, we’re focusing on lateral supine transfers, so people who are lying down can be transferred to another surface where they are lying down. It could be bed to bed, or bed to stretcher, or a stretcher to an imaging table,” explains Singh. Single caregiver, contactless transfers will not only protect staff and patients from injuries, but also curb the spread of infections in health-care facilities and free staff from labour-intensive patient transfers, says Singh. Able Innovations plans to use the $20,000 prize money to help deliver full-scale prototype devices to hospitals who want to test them by the end of 2020. The company is also looking to secure pilot facilities and

has recently opened a seed round of financing to accelerate their path to commercialization. Able is aiming to commercialize the DELTA Platform by mid-2021, with a home version to follow. “The demand for products such as ours is only going to grow due to what’s happening with COVID-19, our aging population and the compounding effect of nursing shortages,” says Singh.

NOVALTE

Novalte tied with eNable Analytics for first-place in the Atlantic Canada competition, held on June 18. Novalte is a Halifax, Nova Scotia-based smart tech solution company whose goal is to help people with mobility challenges easily control their daily living environment. Technology and smart devices have enormous potential to help old-

er adults with mobility challenges live a more independent life and reduce pressures on caregivers. However, not all technology is intuitive to use or even fix when it stops working. Michael Cullen, founder and CTO of Novalte, has developed an elegant solution to this problem by launching the world’s first fully-integrated daily living platform. Novalte deploys smart technology to people with mobility challenges but removes the complexity, so that they can easily take control of their environment and break barriers to living independently. The system, called Emitto, is already deployed on the market to organizations that support individuals with mobility challenges. Users can easily turn on/off their TV, lights or fans, change TV channels, control temperature, open doors, adjust their hospital beds and more via voice or a switch for users who cannot speak. The service also connects them with their loved ones, anywhere in the world, via smart screens – something that’s even more of a priority now with COVID-19 and social isolation. “The best way to describe it would be a super smart home system that can be used in a care environment, facility or at home,” explains Cullen. Novalte also takes care of training the individual and any technical issues so that the user can control their environment without the help of staff or nurses. “For most of my clients, their only problem is interfacing with the world. The world was designed for able-bodied people,” says Cullen. “We just needed that bridge to make the real-world work for them using the best method for the individual – and everybody is different. So, we needed a tool

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LONG-TERM CARE NEWS

that was flexible enough to work very easily for anybody.” What makes the service unique is the remote features, which remove the barrier of technology for individuals and their circle of care so that they can just focus on the benefits. The service improves quality of life as users do not need help for simple tasks, feel empowered and independent, while caregivers can better manage their time. Novalte will use the AGE-WELL prize to hire a firmware engineer to help move the product to the next level in terms of adding more devices to the system. “This is absolutely fantastic,” Cullen says about the prize. “AGE-WELL has been a massive part of the evolution of who we are, and we are grateful for their ongoing support.”

ENABLE ANALYTICS

More than one million Canadians use a walking aid and as our popula-

One of the winning innovations...Able Innovations’ DELTA Platform enables patient transfers with just one caregiver. tion ages, demand will only grow. Most seniors will experience a gradual loss of muscle, balance and mobility, which can increase the risk of falls. Mobility issues and the fear of falling can pre-

vent seniors from getting out and remaining active. eNable Analytics, which shared first place in the Atlantic competition, is using technology to help older adults with

mobility concerns stay engaged and maintain their independence without compromising their safety. The startup, based in Fredericton, New Brunswick, has developed and tested a line of smart-assisted devices, such as walkers, rollators and canes, which help users go about daily activities safely. All devices look and feel like a regular walking aid, but they are augmented with remote monitoring sensors and use machine learning-based analyses to provide regular and proactive insights about physical and behavioural health. The devices were developed in a lab and tested with end-users in collaboration with physicians and physiotherapists. “We can see what kind of surface you’re walking on, if you favour your left or right foot, the length of your steps, your balance etc.,” explains Alex Roberts, entrepreneurial lead at eNable Analytics. Continued on page 36

DID YOU KNOW Nursing and Rehab Home Care services can be provided virtually? 9+$ +RPH +HDOWK&DUH FDQ R΍HU D variety of virtual care options. Contact your service provider or call 1-888-314-6622 or visit www.vha.ca/virtual-care to learn if virtual care is right for you.

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AUGUST 2020 HOSPITAL NEWS 35

LONG-TERM CARE NEWS Continued from page 35

AGE-WELL National Impact Challenge â&#x20AC;&#x153;We also have sensors measuring how much pressure you put on your cane or walker.â&#x20AC;? The real value, he says, is in the data and analytics done behind the scenes. â&#x20AC;&#x153;We can identify the things that lead up to somebody falling and jump in early to suggest exercises or interventions to prevent the fall altogether,â&#x20AC;? he says. The devices can give older adults and their loved ones the peace of mind they need to agein-place through regular feedback and via notifications about changes or trends. A near commercial-ready product will soon be launched into the Canadian market. Devices will be sold at near-cost to facilitate adoption of the platform, and end-users (seniors,

DONâ&#x20AC;&#x2122;T MISS THE THIRD AND FINAL EVENT IN THIS EXCITING SERIES, TO BE HELD ON SEPTEMBER 29 VIA LIVESTREAM, IN CONJUNCTION WITH THE BC SENIORS LIVING ASSOCIATION ANNUAL CONFERENCE. loved ones or circle of care) will pay a monthly subscription fee to unlock premium features, including regular activity and trend reports, and social networking. Physicians, therapists or care facilities, who may adopt the platform for multiple patients or residents, can subscribe to a health professional account to receive additional medical analytics and population summaries.

â&#x20AC;&#x153;The prize will be a big help for us to polish our software development and start rolling out devices into the community soon,â&#x20AC;? says Roberts. â&#x20AC;&#x153;From there, weâ&#x20AC;&#x2122;ll expand out to the province, the country and eventually around the world. The goal is to get it into as many hands as possible and help as many people as we can.â&#x20AC;? AGE-WELL welcomes the win-

ning companies into its network, where they will be nurtured to maximize their impact on the lives of Canadians. Thanks go to all the finalists, the judges and also the sponsors of the competition: Aging2.0 Local I Halifax Chapter, BC Seniors Living Association, Bereskin & Parr LLP, CARP, IBM Canada Ltd., Impact Centre, Innovacorp, Innovation PEI, New Brunswick Innovation Foundation, Ontario Brain Institute, Spectrum Health Care, and YouAreUNLTD. Donâ&#x20AC;&#x2122;t miss the third and final event in this exciting series, to be held on September 29 via livestream, in conjunction with the BC Seniors Living Association annual conference. For H details, go to www.agewell-nce.ca.â&#x2013;

Annie Webb is a Montreal-based freelance writer. Margaret Polanyi is Senior Communications Manager at AGE-WELL. AGE-WELL is a federallyfunded Network of Centres of Excellence. The pan-Canadian network brings together researchers, older adults, caregivers, partner organizations and future leaders to accelerate the delivery of technology-based solutions for healthy aging. For more information, visit www.agewell-nce.ca

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LONG-TERM CARE NEWS

Better collaboration

means better care for long-term care residents By Elaine Mitropoulos s COVID-19 continues to highlight the need for strong collaboration and clear communication among healthcare providers, particularly when it comes to vulnerable older adults, a unique partnership is creating a digital link between St. Joseph’s Healthcare Hamilton (SJHH) and St. Joseph’s Villa in Hamilton, Ont. The integrated care co-ordination platform, Harmony, from Canadi-

an-based PointClickCare, will ensure clear, accurate information flows quickly and easily between the two healthcare providers when transferring patients. The intent is to reduce potential for delays in treatment, errors in care, difficulties obtaining accurate diagnoses, and readmissions to hospital, while improving health outcomes for older adults transferred between hospital and long-term care (LTC). Continued on page 39

Dr. Alistair Ingram, St. Joseph’s Healthcare Hamilton’s Chief of Medicine, says shared digital health systems between hospitals and long-term care facilities are the future of healthcare, and will improve the outcomes of older adults being transferred between the two healthcare providers.

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AUGUST 2020 HOSPITAL NEWS 37

LONG-TERM CARE NEWS

Virtual care shifts into high gear

Brydne Edwards is an occupational therapist at VHA Home HealthCare.

in response to COVID-19 By Crystal Gonder he COVID-19 pandemic has forced all parts of the health care system to rethink the way they deliver care and at VHA Home HealthCare, the more than 10,000 virtual visits completed by our service providers since April, have proven that crisis really is a powerful catalyst. Although virtual care, sometimes called teletherapy or digital health, existed before the pandemic and the technology isn’t new, barriers including confidentiality, compensation and access have always kept these services from being widely used. However, the physical distancing and stay-at-home orders enforced by COVID-19 created an urgent need to provide care whenever possible, without being face-toface. It is entirely new for home care, which primarily delivers care in the intimacy of a client’s home, to try to replicate that same type of connection and the same level of clinical effectiveness, through virtual means. This digital revolution that is happening on an accelerated timeline, is being seen as a silver lining in what has been a scary and challenging time. “VHA was aware of the benefits of virtual care and it was part of our strategic plan for 2020-25 to implement the technology and changes to clinical practices to support this. COVID-19 triggered an immediate necessity and we fast-tracked the work to move it forward within a few weeks,” says Kathy McKenna, Electronic Medical Records Initiative (EMRI) Project Lead at VHA Home HealthCare. “We started with our Rehab Division – physiotherapists, occupational therapists (OTs), speech language pathologists, dietitians and social workers. Virtual care has allowed these

front-line service providers to connect safely and effectively with clients and families at a distance, whenever clinically appropriate,” says Kathy. Although in-person visits are still essential for clients with certain equipment needs, serious feeding challenges, hospital pre-discharge visits and other critical services, virtual care has been implemented for many of our clients and families on a case-by-case basis. For clinicians like Sharon Rosenthal, an OT and Paediatric Clinical Lead, initially there were a lot of doubts around how to have worthwhile, successful sessions that would benefit her clients without a traditional therapeutic connection. “At first, the technology made me quite anxious and overwhelmed – where to put my camera, how my clients would navigate their own devices – and all my sessions were planned down the to the nth degree,” Sharon says. “But already things look and feel much better. I’m more at ease, the connection is surprisingly natural, engagement is good and I’ve built meaningful relationships with my clients.” “To be honest, when I started seeing my clients again in their homes remotely, it was when I started to feel joy again,” says Sharon. “It’s been such a challenge to be quarantined in my home, unsure of how to do my job. I see many young families and thanks to the ability to hold virtual visits, I recently watched one of the babies I work with learning to walk. I was in tears.” Of course, as with any new technology, there have been connection, sound and other technological issues along the way. “I did an entire session sideways, after a client couldn’t change the orientation on their screen. So, I spent a session with my head tilted,”

Sharon laughed. “I would say though that overall, these types of problems haven’t been common.” Brydne Edwards, OT and Professional Practice Specialist and Educator at VHA notes that for virtual care to work, there has to be an entire cultural shift. “Before COVID-19, in-person service was always perceived as the gold standard. For this to be successful, we definitely need to broaden our view of what it means to deliver care,” she says. Service providers have developed a lot of creative ways to offer high-quality care even though they are not faceto-face with their clients. “Some of our clinicians have been making their own videos, demonstrating exercises or activities with items around their homes and utilizing helpful online resources. It has been really interesting to see how effective these strategies are,” says Brydne. “Surprisingly, we’ve also found that in many cases it’s been easier to build relationships virtually, rather than when our clinicians go into homes wearing full protective equipment, which can make commu-

nicating empathy and other emotions more challenging,” she says. “There have been some difficulties to address, such as creating clear documentation guidelines, establishing robust consent processes, clients’ access and understanding of technology, as well as navigating different standards for each professional college,” says Brydne. “But what our teams have been able to do very quickly has been remarkable.” The next phase of VHA’s shift to virtual care will focus on palliative and adult nursing and Community Support Programs and is expected to be rolled out later this month. “I don’t think this is going away. Virtual health is here to stay, there’s no going back to business as usual and the health care system has undoubtedly changed,” says Sharon Rosenthal. “As schools, cities, the country and the world open up more, a hybrid of services will meet the needs of our community and open up care for areas that are not well-served and in situations where in-person visits are H not possible.” ■

Crystal Gonder is a Communications Consultant at VHA Home HealthCare. 38 HOSPITAL NEWS AUGUST 2020

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LONG-TERM CARE NEWS Continued from page 37

Better collaboration “This is one example of how we can improve communication between healthcare providers in our own community to make sure no one falls through the cracks,” says Dr. Alistair Ingram, Chief of Medicine at SJHH. “Having shared systems that talk to one another is a step towards the future of healthcare, where we see seamless connections between regional healthcare providers and easily accessible patient information wherever the patient is being cared for.” This fast, bi-directional exchange of medical information will bring many benefits in terms of speed and accuracy of information, which is important now more than ever as we are faced with the challenges of a pandemic. For hospital patients going to an LTC home, their hospital team will be able to send medical information to their LTC team – directly from the hospital system to the LTC home. The same will be true in reverse for residents of an LTC home going into hospital. “We know transitions between long-term care and hospitals can have the potential for medication errors and poor communication can hurt older adults,” says Dr. Hugh Boyd, Medical Director at St. Joseph’s Villa. “When transferring care, many of us will try to send thorough information or call directly to receiving physicians, but this can sometimes result in over 100 pages being sent either electronically or via fax. This platform will eliminate clinicians wasting time sorting through fragmented data and allow more time to focus on caring for patients. This will save time and save lives.” Both SJHH and St. Joseph’s Villa already collaborate under St. Joseph’s Health System (SJHS), a leader in integrated care creating this unique opportunity to test the cooperative pilot project. A multi-disciplinary team from across SJHS will work with PointClickCare, which provides the cloud-based digital health information system used at St. Joseph’s Villa, to enable the secure two-way exchange of patient data with Dovetale (Epic), the hospital information system used at SJHH. Following the pilot, and once the benefits of the project are evaluated, www.hospitalnews.com

Dr. Hugh Boyd, Medical Director at St. Joseph’s Villa in Hamilton, Ont., says the seamless transfer of patient information between hospital and long-term care homes has the potential to save time and lives. the hope is to expand the solution to other healthcare providers in Hamilton, across the province, and Canada-wide. Not only will the solution help with the transfer of COVID-19 patients from LTC to hospital, but it will also enable broader goals around integrated care and information sharing, which are fundamental to the success of the newly created Ontario Health Teams. Additionally, the solution could help reduce the number of unnecessary emergency transfers, as well as the time residents may be waiting for treatment. The project is funded in part by the CAN Health Network as an innovative solution to address important challenges in our healthcare system. The CAN Health Network was created in July 2019 as a result of a Federal Government investment totaling $7 million, of which the Federal Economic Development Agency for Southern Ontario (FedDev Ontario) and Western Economic Diversification Canada (WD) each contributed $3.5 million. This investment established the Network in Ontario and the West, with expansion to the East, Quebec and the North to come. “The partnership created with the CAN Health Network, PointClickCare and St. Joseph’s Health System showcases Canadian talent in supporting our older adults in long-term care homes,” says Dr. Dante Morra, Chair of the CAN Health Network. “This initiative will help strengthen our healthcare system by addressing healthcare challenges like COVID-19 while helping Canadian innovators like PointClickCare scale faster across H Canada.” ■

Elaine Mitropoulos works in Public Affairs at St. Joseph’s Healthcare Hamilton.

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