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Contents December 2019 Edition
IN THIS ISSUE:
Losing the fight against superbugs
8
▲ Cover story: Robotic interventional brain surgery
14
▲ How safe is our care?
10
▲ Using smart technologies
COLUMNS
24
Guest editorial .................4 In brief .............................6 Ethics .............................15 From the CEO’s desk .....16 Safe medication ............18 Long-term care ...............26 Nursing pulse ................30 Evidence matters ...........31 Cover photo: Krembil Brain Institute/UHN.
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▲ The future of healthcare
12
Special Focus: Radiology
20
▲ Revolutionizing acute stroke management
22
Legalizing medical aid in dying for Canadians living with disabilities: What does this say about us?
By Ewan Goligher
n September 11, a Quebec judge overturned the law restricting euthanasia (widely referred to as ‘medical aid in dying’) to patients in whom natural death was “reasonably foreseeable.” The federal government has indicated that they will not appeal the decision and are prepared to modify the law accordingly. These developments require sober consideration for they speak volumes about the inexorable logic of euthanasia and about our attitudes towards those with disabilities. The Quebec ruling must be overturned to prevent further cascading demands on assisted dying legislation and to safeguard our most vulnerable citizens. Euthanasia is offered as a means of escaping pointless and irremediable suffering. Yet we need not be dying in order to experience suffering that seems pointless and hopeless to us. Therefore, restricting euthanasia to those in whom natural death is reasonably foreseeable violates the intrinsic logic of euthanasia. If life is sufficiently hard and suffering sufficiently grievous, we might come to think that we are better off dead long before natural death becomes reasonably foreseeable. Such is the bleak logic of euthanasia.
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Following this logic, is it possible to put any limits on euthanasia at all? Just what kinds of suffering should be eligible for euthanasia? Surely psychological and existential suffering are just as (if not more) unbearable than physical pain. Therefore, patients with protracted severe depression and mental illness should also be eligible, as some argue. What if I merely anticipate grievous suffering and this makes life pointless to me? What if my condition might get better but I don’t want to wait and endure to find out? How disabled do I need to be for my suffering to qualify for euthanasia? And who gets to answer these questions? Any attempt to impose answers to these questions upon individual patients violates the commitment to personal autonomy and control that underpins the logic of euthanasia – as Dying with Dignity Canada states: “My life, my choice.” Followed to its logical conclusion, euthanasia is really for anyone at any time under any circumstances, provided they want it. Those who accept this logic will not be satisfied until all restrictions are removed. Continued on page 6
Dr. Ewan Goligher is an Assistant Professor of Medicine in the Interdepartmental Division of Critical Care Medicine at the University of Toronto.
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Monthly Focus: Professional Development/Continuing Medical Education (CME)/ Human Resources: Continuing Medical Education (CME) for healthcare professionals. The use of simulation in training. Human resource programs implemented to manage stress in the workplace and attract and retain healthcare staff. Health and safety issues for healthcare professionals. Quality work environment initiatives and outcomes.
Monthly Focus: Gerontology/Alternate Level of Care/Rehab/ Wound Care/Procurement: Geriatric medicine, aging-related health issues and senior friendly strategies. Best practices in care transitions that improve patient flow through the continuum of care. Rehabilitation techniques for a variety of injuries and diseases. Innovation in the treatment and prevention of wounds.
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THANKS TO OUR ADVERTISERS Hospital News is provided at no cost in hospitals. When you visit our advertisers, please mention you saw their ads in Hospital News. 4 HOSPITAL NEWS DECEMBER 2019
Hospital News is published for hospital health-care professionals, patients, visitors and students. It is available free of charge from distribution racks in hospitals in Ontario. Bulk subscriptions are available for hospitals outside Ontario. The statements, opinions and viewpoints made or expressed by the writers do not necessarily represent the opinions and views of Hospital News, or the publishers. Hospital News and Members of the Advisory Board assume no responsibility or liability for claims, statements, opinions or views, written or reported by its contributing writers, including product or service information that is advertised. Changes of address, notices, subscriptions orders and undeliverable address notifications. Subscription rate in Canada for single copies is $29.40 per year. Send enquiries to: subscriptions@ hospitalnews.com Canadian Publications mail sales product agreement number 42578518.
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NEWS
Thinking differently about innovation
By Sean Peacocke
common strategy organizations use to increase innovation is to throw more money at it. Yet we know success factors for innovation comes down to more than just funding, it involves modifying structure, process, people, training and culture to embed innovation in all areas of your organization. Experts at Holland Bloorview Kids Rehabilitation Hospital in Toronto, Ontario have developed a new training program that focuses on innovative thinking and culture rather than the traditional focus on practice, invention or technology. “We realized that in order to solve really complex challenges within childhood disability, we needed to support and nurture our leaders to unleash the creative potential within their teams,” says Dr. Kathryn Parker, co-lead of the program and senior director of the hospital’s Teaching and Learning Institute. In 2017, Holland Bloorview launched its strategic plan, No Boundaries. In order to create a ‘no boundaries’ ethos within the organization, there was a need to think differently about how to structure and deliver services. The Accelerate Innovative Mindsets (AIM) program was designed to support innovative thinking amongst Holland Bloorview leaders as they work with their health care teams to move strategic initiatives forward. AIM was built on best practices in Design ThinkingTM methodology and is being applied in solving complex problems for children, youth and families living with disability. AIM supports development by providing opportunities for leaders to build their capabilities in core areas related to innovative thinking through the following activities: an orientation to innovative thinking, engaging in innovation simulations, participating in a design thinking workshop, and developing a learning plan. In addition, leaders host an Innovation Jam – a purposeful gathering of diverse perspectives to solve a complex problem – where they use design thinking methodology with their teams. “The Innovation Jam really enabled us to challenge our assumptions about
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The Accelerate Innovative Mindsets (AIM) program was designed to support innovative thinking amongst Holland Bloorview leaders as they work to move strategic initiatives, like No Boundaries, forward.
what we thought the solutions were,” says Laura Thompson, team lead and occupational therapist at Holland Bloorview, involved in co-creating innovative transition pathways with youth and their families. “It took our work to a place we didn’t think we could get to.” Throughout AIM, leaders also have access to innovation resources (e.g. articles) and ongoing access to coaching sessions. “Coaching provided participants an opportunity to bring clarity to their ideas, embed design thinking principles and accelerate their innovative projects,” says Doug Miron, co-lead of the program and director of Organizational Development and Learning at Holland Bloorview. So far, the AIM program has trained eight leaders in innovative thinking and their work has had over 300 points of contact across the hospital and within the system. The participation of leaders in the program makes a notable impact on them, their teams and, most importantly, their work in childhood disability. “The AIM program was instrumental in helping us develop a successful internal engagement approach for Dear Everybody (www.DearEverybody.ca), Holland Bloorview’s cam-
paign to end childhood disability stigma,” says Stewart Wong, vice president of communications, marketing and advocacy at Holland Bloorview. “The innovation framework provided us with the tools and language to truly understand the perspective of our staff and what would enhance their ability
to be champions of the [Dear Everybody] campaign.” The AIM program has been embedded within the Organizational Development and Learning department with the plan to continue sharing and spreading innovative thinking methH odology across the hospital. ■
Sean Peacocke is the manager of strategy and Centre for Leadership at Holland Bloorview Kids Rehabilitation Hospital.
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DECEMBER 2019 HOSPITAL NEWS 5
IN BRIEF
Legalizing medical aid Continued from page 4 Lurking behind this logic are assumptions about autonomy and vulnerability. A decision expresses your autonomy insofar as you “own” the decision: it reflects your wishes and values and is not imposed upon you in any way. This notion of autonomy assumes that all of us can rise above the forces acting upon us from without, and here we detect a grave possibility of error. Overt efforts at coercion may be easily detected and resisted, but the subtle influences of societal valuation are harder to appreciate and far more irresistible. “No man is an island entire of itself” goes John Donne’s famous line. We are, in his words, “a piece of the continent,” part of an interdependent network of relationships that powerfully and unavoidably influence how we see ourselves and our significance in this world. How then might general social acceptance and approval for euthanasia of persons with disabilities influence their sense of personal value? What does social approval for this act say about us and our values and attitudes toward those with disabilities? Do we view those with disabilities as merely expendable, free to have their lives ended if they so choose without protest on our part? By comparison, would we protest if a healthy young woman sought to end her life because of persistent bullying on social media? A society that prizes and prioritizes the most vulnerable amongst us is a safe place for all of us to flourish. Such a society makes every effort to communicate that each of us matters and prohibits anything that diminishes our individual value. The death of those with disabilities is as profound a loss for all of us as much as is the death of those without disabilities. ‘Any man’s death diminishes me /because I am involved in mankind /And therefore never send to know for whom the bell tolls/it tolls for thee.’ The Quebec Court’s decision of September 11, 2019 must be overH turned. Canadians must demand it. ■
Health spending in Canada reaches
$264 billion
6 HOSPITAL NEWS DECEMBER 2019
igures released by the Canadian Institute for Health Information (CIHI) show that the country’s health spending continues to grow and is expected to reach $264 billion in 2019 – a four per cent increase over last year. National Health Expenditure Trends, 1975 to 2019 shows that Canada continues to make investments in health care. While expenditures vary across the country, health spending is expected to reach $7,068 per Canadian – up from $6,867 in 2018.
in Canada, accounting for 66 per cent of private-sector spending, compared with 10 per cent of total public-sector spending. In 2017, the latest year for which private-sector data is available, payments by private insurance companies accounted for 41 per cent of private-sector spending, while out-ofpocket expenditures represented 49 per cent.
PRIVATE-SECTOR FUNDING
• Overall, health spending as a share of Canada’s gross domestic product (GDP) is trending upward. It is estimated that health expenditures will represent 11.6 per cent of Canada’s GDP in 2019. • Hospitals continue to use the largest share of health dollars (27%), followed by drugs (15%) and physicians (15%). These three areas have consistently accounted for the
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Private-sector health care spending has remained relatively consistent over the past two decades, funding around 30 per cent of Canada’s total health expenditures. Drugs and Other Professionals (such as Dental Services and Vision Care Services) are the top categories of private-sector spending
NATIONAL HEALTH EXPENDITURE BY THE NUMBERS
majority of health spending, but this year physician spending is expected to see the biggest growth overall – a four per cent increase from last year. • Health care spending is highest on seniors. Although per-person spending increased considerably with age – from $6,656 for those age 65 to 69 to $20,793 for those age 80 and older – population aging is a modest driver of increasing health care costs, at about one per cent per year. • Canada continues to rank among the highest per capita spenders on health among Organisation for Economic Co-operation and Development (OECD) countries. For 2018, the latest year for which international data is available, the OECD reports that Canada’s per capita spending on health care was $6,448, comparable to that of the Netherlands (CA$6,855), France (CA$6,436) and Australia (CA$6,488). ■ H
Hospital infections declining in Canada here is good news on the infection front: infections acquired by patients in Canadian hospitals are declining, with a 30 per cent reduction between 2009 and 2017, according to new research in CMAJ (Canadian Medical Association Journal). However, continued focus is necessary to identify and prevent emerging antimicrobial-resistant pathogens, and infections with medical devices, such as urinary or intravenous catheters. Health care–associated infections are a substantial issue worldwide. In the United States, an estimated five per cent of patients admitted to hos-
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HEALTH CARE– ASSOCIATED INFECTIONS ARE A SUBSTANTIAL ISSUE WORLDWIDE. pital in 2002 developed an infection, resulting in 1.7 million infections and 98 000 deaths. A series of studies, conducted by a team of researchers with the Canadian Nosocomial Infection Surveillance Program (CNISP), included data from hospitals from nine Canadian provinces in 2002 and 2009, and all 10
provinces in 2017. The proportion of patients with a hospital-acquired infection increased from 9.9 per cent in 2002 to 11.3 per cent in 2009, and decreased to 7.9 per cent in 2017, a 30 per cent decline. Urinary tract infections (32%) were the most common infection, followed by pneumonia (23%), surgical site infection (20%), bloodstream infection (15%) and Clostridioides difficile infection (9%). Infection rates in intensive care units declined 29 per cent. “There is no single reason for the overall decline in infection types, which suggests Canadian hospitals have used a variety of methods to www.hospitalnews.com
IN BRIEF
New guideline for Parkinson disease comprehensive new Canadian Guideline for Parkinson Disease, 2nd Edition, provides practical guidance for physicians, allied health professionals, people with Parkinson’s and families on disease management. CMAJ (Canadian Medical Association Journal www.cmaj.ca) published the new guideline accompanied by an easy-to-reference infographic and podcast. Since publication of the first Canadian guideline in 2012, there have been significant advancements in Parkinson’s disease. The new guideline, sponsored by Parkinson Canada, shows the latest evidence and advances in diagnosis, treatment and symptom management; the guideline contains a new section on palliative care through all phases of the disease. An interdisciplinary team of experts from across Canada helped develop the second edition including 13 new recommendations, which consolidate new evidence and address gaps. “Depression and anxiety are common symptoms of Parkinson patients and can be harder to recognize. Physicians should feel more comfortable with treating the depression and anxiety as these directly impact the quality of life of people with Parkinson’s and their caregivers,” says Dr. David
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prevent infection, such as better hand washing, antimicrobial stewardship to prevent C. difficile and other measures,” says Dr. Geoffrey Taylor, University of Alberta Hospital, Edmonton, Alberta. In a related commentary Dr. Jennie Johnstone, Public Health Ontario and coauthors write, “[a]lthough these rates are low, there are some concerning trends. The proportion of health care–associated infections caused by antimicrobial-resistant organisms was stable or increasing for all pathogens, and carbapenamase-producing Enterobacteriaceae, which are emerging antimicrobial-resistant pathogens, www.hospitalnews.com
Grimes, lead author of the Canadian Guideline for Parkinson Disease and Division Head, Neurology, The Ottawa Hospital, University of Ottawa Brain and Mind Research Institute. “Our message to individuals is ‘don’t wait.’ There are professionals who can directly improve a person’s quality of life through early and regular intervention,” says Joyce Gordon, Parkinson Canada CEO. “There is a lot a person can do now to live life to the fullest, working together with their healthcare team to mitigate symptoms and improve health outcomes,” she adds. The guideline includes 97 recommendations divided into five sections for ease of use: • Communication (including families and caregivers) • Diagnosis and progression • Treatment • Non-motor features • Palliative care “A limitation to implementing the guideline is the lack of access to healthcare providers experienced in caring for people with Parkinson’s disease,” says Dr. Grimes. “In addition to specialist physicians, we need more nurses, and speech, occupational and physical therapists with training in this area, as well as appropriate palliH ative care for Parkinson patients.” ■
were identified for the first time in the 2017 survey.” “Without ongoing efforts to improve and reduce health care–associated infections and antimicrobial resistance and without frequent measurement of our performance as a country, it is likely that the gains seen in this study will not be sustained and that Canada’s antimicrobial resistance problem may become unmanageable,” write the commentary authors. “Trends in health care–associated infections in acute care hospitals in Canada: an analysis of repeated point-prevalence surveys” was pubH lished September 9, 2019. ■
Celebrating improvements to patient safety uring this year’s Canadian Patient Safety Week, hospitals from across the country celebrated important improvements to patient safety. “Three years ago, hospitals from seven provinces joined forces to raise awareness among pharmaceutical suppliers of what our hospitals needed to help safeguard our patients,” says Spencer Tuttle, Director, Lower Mainland Pharmacy Services.
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THE PAN-CANADIAN EFFORT WAS COORDINATED THROUGH HEALTHPRO “By working with industry, we have made important advancements in barcoding, advance notification of product changes and new products that can help mitigate medication errors and make the supply chain more efficient.” The pan-Canadian effort was coordinated through HealthPRO, the national group purchasing organization. Successes achieved to date include:
1. Twenty per cent increase in barcodes on a medication’s unitof-use; 2. Implemented a national protocol for the advance notification of product changes; Many pharmaceutical suppliers now provide at least 60 days’ advance notice of product changes to HealthPRO, who in turn communicates them to hospitals across the country to adjust their automation protocols. This advance notification can help mitigate a cost to the system which simply cannot be measured. 3. Helped introduce 36 new commercially available medications that meet patient safety objectives Through this collective effort, hospitals helped accelerate the development of fit-for-purpose medications to facilitate appropriate and accurate dosing. These are new products, such as lower strength medications in the actual dose required by patients, that suppliers have produced based on the specific needs of hospitals across the country which enhance patient safety and bring efficiency to the internal hospital supply H chain. ■
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NEWS
We’re losing the fight against superbugs By Dr. Steven J. Hoffman and Dr. Charu Kaushic iscovering antibiotics in 1928 was among the most significant health advances in history, as it finally equipped humanity with a simple and effective treatment for bacterial infections. Until then, bacterial infections were commonly treated through amputation of the infected body part – and often resulted in death. For decades, we lived a relatively carefree existence with regard to bacterial infections, knowing that we had readily available antibiotics as a dependable line of defence. Unfortunately, through over-use, our antibiotics are no longer working as they should. The bugs have evolved into superbugs that have grown impervious to our treatments – a process known as antimicrobial resistance. A typical scenario goes something like this: a patient is admitted to hospital for a medical procedure – say, a hip replacement or mastectomy. Following surgery, the patient develops an infection. The doctor administers antibiotics to treat the infection, but the bacteria have developed immunity to that particular drug. The doctor then tries second, third, or fourthline treatments in an attempt to stop the infection. In some cases, one of those alternatives works and the patient is saved. In other cases, the infection spreads to the blood, and the patient dies. According to a new Council of Canadian Academies report, around 26 per cent of bacterial infections in Canada are currently resistant to antibiotics, which caused 5,400 deaths in Canada last year (similar to Alzheimer’s disease), $1.4 billion in extra health care costs, and $2 billion in lost GDP. But this rate of resistance is increasing. If the rate reaches 40 per cent by 2050 – a likely scenario – that would mean a cumulative 396,000 deaths in Canada from antimicrobial resistance between now and then, along with $120 billion in extra hospital costs and $388 billion in lost GDP. The time has come for governments around the world to take this
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threat seriously – and to take serious action – if we are to avert this public health crisis. Action begins with ensuring access. There are still millions of people around the world who lack access to life-saving antibiotics. In our increasingly interconnected world, this has implications for all of us, as superbugs know no borders, and a drug-resistant microbe in one country is just a flight away from spreading to other countries.
acceleration of antimicrobial resistance – the human health problem – is something that we can manage. For doctors and veterinarians, this means prescribing antibiotics responsibly. For citizens, this means not demanding antibiotics for simple coughs and colds – for which we are usually better off staying home, drinking lots of liquids, and getting rest. The final step is innovation. We currently have an innovation problem, as we do not have successful
AROUND 26 PER CENT OF BACTERIAL INFECTIONS IN CANADA ARE CURRENTLY RESISTANT TO ANTIBIOTICS, WHICH CAUSED 5,400 DEATHS IN CANADA LAST YEAR. The second step is conservation. We need to protect the effectiveness of our existing antibiotics, because each unnecessary use – whether in humans, animals, or agriculture – accelerates resistance. Antimicrobial resistance is a natural and continual evolutionary process; however, the
models for incentivizing the development of new antibiotics, alternatives to their use, and strategies for conserving them. Conversely, superbugs excel at innovation – they continuously evolve. We humans need to be smarter than the superbugs. We need to stop playing catch-up, get
ahead of our opponent, and maintain the lead. This November 18-24 was the United Nations’ World Antibiotic Awareness Week – an opportunity to bring further attention to this issue. By encouraging such conversations, it is our hope that we will see a growing sense of urgency and momentum toward finding solutions. Canada, for its part, is taking a leadership role in mobilizing expertise and research to tackle this challenge. A Pan-Canadian Action Plan for Antimicrobial Resistance is under development and will provide a roadmap for action. Canada is also home to many leading scientists who are experts in this field and have much to contribute to the development of new antibiotics, alternative treatments and conservation strategies. What we do know is that this challenge will not be solved with existing tools. If we hope to return to a world where we can count on antibiotics when we need them, we need new knowledge, new drugs, and a commitment to act internationally H as a unified global community. ■
Dr. Steven J. Hoffman and Dr. Charu Kaushic are the Scientific Directors of the Institute of Population & Public Health and the Institute of Infection & Immunity, respectively, with the Canadian Institutes of Health Research – the Government of Canada’s health research funding agency. 8 HOSPITAL NEWS DECEMBER 2019
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Cataract patients have choices Learn about your lens options before you see your surgeon he stars at night? I hadn’t seen them for a decade. They are breathtaking,” recounts Tracey Dorey, retired Vancouver school teacher. “I’ve always loved nature, colours and textures, but I didn’t realize how much I was missing until I had cataract surgery.” Tracey was among 2.5 million Canadians living with cataracts each year. A recent survey commissioned by Leger, revealed that over half of Canadians do not know much about cataracts and cataract surgery; and 59 per cent are unaware that there are options to treat cataracts and other vision conditions at once. The survey also found that fear is a barrier to having the procedure done despite the fact that cataract surgery is one of the most commonly performed procedures in Canada and the only way to restore vision loss due to cataracts. This is particularly concerning as cataracts are one of the leading causes of blindness and low vision in age-related eye diseases.² “We often hear from patients that they are worried or nervous about cataract surgery,” says Dr. Kathy Cao, a Toronto based ophthalmologist. “While every surgery should be carefully considered, cataract surgery is generally safe and done on an outpatient basis, which means patients go home the same day after surgery, and often start to notice vision improvements within a couple of days and may return to regular life activities shortly after.” More than 350,000 cataract procedures are performed each year in Canada, where the natural lens that has become clouded is removed and replaced with an intraocular lens. This minimally invasive procedure is completed in less than 30 minutes and re-
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HALF OF CANADIANS DO NOT KNOW MUCH ABOUT CATARACTS AND CATARACT SURGERY; AND 59 PER CENT ARE UNAWARE THAT THERE ARE OPTIONS TO TREAT CATARACTS covery is usually very quick. Most patients notice an improvement in their vision within 24 hours, and return to regular activities soon after surgery. Before having cataract surgery, it is important that patients have informed discussions with their surgeon about their vision goals and ocular health. For years, cataract replacement lens options were limited and monofocal
lenses were the only option. Now patients have the option of trifocal lenses that provide excellent vision at multiple distances allowing patients to see everything near, far and everything in-between. “If patients choose trifocal lenses, it may help remove dependency on glasses, which is very appealing to those who live active and busy life-
styles,” says Dr.Cao. “For many of my patients, the freedom to see clearly without glasses has greatly improved their quality of life.” During her cataract surgery, Tracey received the Alcon PanOptix® trifocal lenses. “I had been living in a world of muted colour and indistinct shape. I can now go outside and see detail on the side of a mountain, or the birds in the sky. Since my surgery, my whole outlook about who I am and what I can do has changed. I feel like a whole new person – it’s been such a big turning point in my life.” To learn more about cataracts, cataract surgery and intraocular lens options speak with your eye care profesH sional and visit SeeTheFullPicture.ca. Q
1 Cataract Awareness Survey, 2018. This survey was conducted online by Leger, The Research Intelligence Group, on behalf of Alcon Vison Care from November 8 until November 18, 2018, among 1,503 Canadians age 55 through 79, using Leger’s online panel LegerWeb. A probability sample of the same size would yield a margin of error +/- 2.5%, 19 times out of 20 ² Common Eye Disorders. Centres for disease control and prevention, 2015. Accessed from www.cdc.gov/visionhealth www.hospitalnews.com
DECEMBER 2019 HOSPITAL NEWS 9
NEWS
How safe is our care?
By Anne MacLaurin, Virginia Flintoft, Wayne Miller and Alex Titeu ll healthcare leaders, providers, patients, and the public should wrestle with a fundamental question: How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky? Jim Reinertsen, MD, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, “Are we safe or just lucky?” “The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.” Professor Charles Vincent, Professor of Psychology at Oxford University, advocates that assessing safety is not the same as counting harm. As the first author of the Measurement and Monitoring of Safety framework, he believe it is critical for us to ask five questions, each related to a specific dimension of safety, in order to determine whether an organization is safe. This approach is one often used by industry that looks at leading and lagging indicators, and relies on soft intelligence. A holistic view of safety prompts leaders and providers to be inquisitive and empowers everyone to take a proactive role in safety.
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THE FIVE CRITICAL QUESTIONS ARE:
1. Has patient care been safe in the past? Systematically reviewing existing measurement and monitor-
A framework for safety measurement and monitoring Source: Vincent C. Burnett S. Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013
ing of past harm can increase your understanding and help you to respond appropriately to harm when it occurs. 2. Are our clinical systems and processes reliable? This dimension gauges the probability that a task, process, intervention or pathway will be carried out or followed as specified. 3. Is care safe today? Sensitivity to operations focuses on the day-today, hour-by-hour and even minute-by-minute management of safety, bringing together a mix of intelligence to help staff, clinicians, managers and leaders assess and act upon safety in real time.
10 HOSPITAL NEWS DECEMBER 2019
4. Will care be safe in the future? By focusing on the identification of possible sources of future harm, you can work to become more resilient to them. Don’t wait for things to go wrong before trying to improve safety. 5. Are we responding and improving? The development of systems to promote a cycle of learning and sharing from safety incidents, multiple sources of safety intelligence and insights developed through the other domains. Integration and learning is the glue that holds a rounded safety picture together. “The Framework changes the nature of the conversation to being more
mindful and forward-thinking,” says Wayne Miller, Senior Project Manager, Canadian Patient Safety Institute and MMS coach. In 2017, the Canadian Patient Safety Institute launched a measurement and monitoring of safety demonstration project, led by Dr. Ross Baker at the University of Toronto. An 18-month Safety Improvement Project was subsequently launched in 2018, to support healthcare teams in rewiring their thinking on patient safety and to work within their organizations to foster and promote this new approach to safety. The coaches supporting the MMS collaboratives have learned that this
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NEWS
THE TRADITIONAL PRACTICE HAS BEEN TO LOOK IN A REAR VIEW MIRROR, FOCUSING ON PAST HARM DATA AS A MEASURE OF SAFETY. A NEW APPROACH THAT IS CHANGING THE WAY WE THINK ABOUT SAFETY IS TO LOOK AT WHAT MAKES AN ORGANIZATION SAFE, BEING PROACTIVE AND CONSIDERING WHAT LIES AHEAD, RATHER THAN JUST A NARROW FOCUS ON WHAT HAS HAPPENED IN THE PAST. THE MEASUREMENT AND MONITORING OF SAFETY IS TEACHING US TO MOVE AWAY FROM MANAGING RISK, TO CREATING A MORE HOLISTIC VIEW OF SAFETY.
expanded view, helps to provide a shared and consistent understanding of safety. It empowers everyone to take a proactive role and promotes a culture of collective responsibility for safety. MMS promotes the importance of the contribution that patients and carers make to safer care. Most importantly, it reinforces the message that safety is more than counting harm. “It is exciting to see the transformation within the teams and their under-
standing and focus on patient safety,” says Anne MacLaurin, Senior Program Manager, Canadian Patient Safety Institute and MMS coach. Danielle Bellamy, Director of Continuing Care, Yorkton & District Nursing Home (Saskatchewan Health Authority) participated in the MMS collaborative. She says that the value of this work is how it empowers team members to focus on the presence of safety.
“We often speak about how safety is everyone’s responsibility, but team members have historically told us that they don’t feel they have the tools to take action,” says Bellamy. “This Framework has given us the opportunity to co-create a tool to empower our frontline team to not only identify the potential for harm, but to work towards reducing or eliminating the harm. As a result, we are witnessing a shift in the culture of safety within our care home, and providing a
safer environment for both our residents and team.” Crystal Browne, Director Clinical Operations, Alberta Health Services – Area 4 (North Zone) says, “I think the biggest takeaway I have gained from this learning collaborative is that safety is not a ‘project’ with a defined beginning, middle and end. It’s an ethos of constant inquiry at all levels of the organization as we try to answer the questions of is care safe today? H and will it be safe tomorrow?” ■
Virginia Flintoft, Anne MacLaurin, Wayne Miller and Alex Titeu are coaching the 11 teams from across the country participating in the MMS Safety Improvement Project, helping them to implement this new approach to measuring and monitoring of safety. For more information, visit www. patientsafetyinstitute.ca
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DECEMBER 2019 HOSPITAL NEWS 11
NEWS
The future of healthcare depends on a new vision to fuel innovation
By Neil Fraser ntario’s recently announced strategy to expand digital and virtual healthcare over the next couple of years is encouraging for all of us working to create a brighter future for our ailing health system. The government’s Digital First for Health Strategy promises to introduce more patient access to video visits with physicians, enable patients to book appointments online and improve healthcare provider access to electronic patient records. These changes will help harness the power of technology to improve the patient experience and make it easier for doctors and clinical staff to provide more timely care. But they are only a small piece of the puzzle required to build a healthcare system that can meet the evolving needs of Canadians, many of whom are living longer, experiencing more cases of chronic conditions, and want to stay in their homes as long as possible. The stark reality is that Canada – once heralded as an innovator for implementing a publicly funded healthcare system across the country – has been underperforming for years on the world stage when it comes to healthcare. We have not evolved our system and policies to leverage the technology, talent, processes, and treatments that could both improve clinical outcomes and reduce the overall cost of care. While several leading healthcare systems outside of Canada are modernizing medical care by providing patients with digital access to medical records, using advanced robotics for surgeries, and enabling big data to better monitor and improve health outcomes, Canada is falling behind. So, what’s holding back healthcare innovation in Canada?
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CANADA HAS BEEN UNDERPERFORMING FOR YEARS ON THE WORLD STAGE WHEN IT COMES TO HEALTHCARE. The bottom line is that the country’s innovation potential has not been realized and one of the key barriers holding us back is the failure to develop and implement policies that support the full innovation cycle from creation through to adoption. Fundamentally, Canada is ignoring demand-side innovation policies. Our innovation policies are primarily focused on the supply of innovation – for example, through economic development, such as creating superclusters – which has produced a big talent pool of people who do great research in Canada. But there has been almost no focus on policies that address the demand for the innovations stemming from that talent pool and research. Demand-side innovation policies recognize that feedback-linkages are required between supply and demand in the innovation process. From a health perspective, demand-side innovation means the healthcare system (that is, federal, provincial and territo-
rial governments) proactively seeking out innovative solutions to respond to a healthcare challenge, rather than the current system where companies with innovative technologies try to sell innovative solutions to the healthcare system. To create a future where our public policy approach fosters healthcare innovation instead of holding it back, we also need to re-examine the way we cover the costs of delivering healthcare. Our current funding mechanisms, procurement policies and reimbursement methods act as systemic barriers that hold back healthcare innovation. Canadian physicians continue to be remunerated predominantly through fee-for-service (FFS) payment models. The problem with FFS payment models is that they fail to incentivize the creation of healthier populations and instead incentivize providing services over patient outcomes.
Compounding the problem, the global budgets through which most Canadian hospitals are funded are usually fully allocated by the time they are approved each year, providing little or no opportunity to invest in new technology or processes that would improve outcomes or save money over the longer term. Ineffective hospital procurement policies also inhibit innovation and weaken healthcare performance, with little accountability for operational efficiency and patient outcomes. Procurement teams too often focus almost exclusively on the lowest up-front prices for products and services, even if a product or service that may be more costly in the short term could ultimately produce greater savings and better patient outcomes in the long term. A final obstacle that needs to be addressed to spur innovation is the unnecessarily long and complicated process for obtaining reimbursement for new technologies. Unlike in the UK or the US, even when technologies do receive a positive recommendation in Canada, there is no guarantee of funding or adoption. Key examples of insufficient funding despite positive health technology assessments include continuous glucose monitors for use with integrated insulin pumps for type 1 diabetes and transcatheter aortic valve implantation for heart failure, which, if used, avoids open heart surgery. This reimbursement challenge provides little incentive for innovative companies to introduce new technologies to the Canadian market and limits patient access to care that could improve outcomes. Our healthcare system may be ailing, but the prognosis for the future is good – provided all major players in the health system are willing to adapt and transform to better fit in with the changing world around us and the fuH ture of healthcare. ■
European Commission, Directorate-General for Research and Innovation (2015). Supply and Demand Side Innovation Policies: Final Report (Brussels: European Commission, February 2015).
Neil Fraser, president of Medtronic Canada, and Melicent Lavers-Sailly, senior manager – stakeholder engagement & strategy, Medtronic Canada, recently co-authored a paper published in Longwoods.com about demand-side innovation — Imperative for Healthcare: To Lead with Outcomes & Value: the Need for ‘Demand-Side’ Innovation in Canada’s Healthcare Ecosystem. 12 HOSPITAL NEWS DECEMBER 2019
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COVER
During the procedure, Dr. Pereira led the intervention from a control station with joysticks in hand to maneuver the robotic arm.
World first robotic interventional
Photo credit: Krembil Brain Institute/UHN.
aneurysm treatment By Roger Boyle ver 62,000 strokes occur in Canada each year, and for patients, access to treatment is critical to survival and improved recovery. In November, the Neuro Interventional Radiology team at the University Health Network’s (UHN) Toronto Western Hospital took the first step towards enabling greater access to stroke treatment by performing the first-in-human robot-assisted neuro interventional procedure, with a remote operation system. “Precision is a key element of neurovascular interventions,” says Dr. Vitor Mendes Pereira, neuroradiologist with UHN’s Joint Department of Medical Imaging (JDMI), and neurosurgeon, Krembil Brain Institute. “We recognized that the robotic system could immediately bring an added level of precision in treating this patient, reducing the risk of an aneurysm rupture, and enhancing quality of care.” “This is the only robotic system in the world capable of this type of neuro interventional procedure, and we knew it could help in our treatment of the patient.”
THIS IS THE ONLY ROBOTIC SYSTEM IN THE WORLD CAPABLE OF THIS TYPE OF NEURO INTERVENTIONAL PROCEDURE, AND WE KNEW IT COULD HELP IN OUR TREATMENT OF THE PATIENT.
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The landmark robotic-assisted aneurysm case marked a significant milestone in interventional medicine as the first step in building towards a new treatment paradigm for patients suffering from neurovascular disease. During the procedure, Dr. Pereira led the intervention from a control station with joysticks in hand to maneuver the robotic arm. Through the digital controls, he guided a micro catheter with millimetric precision through vessels in the brain and deployed a coil, limiting blood flow to the aneurysm. Fellow neuroradiologists, Drs. Timo Krings and Patrick Nicholson, provided bedside physician support while medical radiation technologist, Nicole Cancelliere, acted as the bedside robotic technician. Prior to the procedure, Dr. Pereira performed a rehearsal on a 3D-printed
model with the exact anatomy of the patient, a 64-year-old female. Using the model allowed Dr. Pereira to develop a plan for the novel robotic procedure and ensure an optimal treatment approach. “I knew what I wanted to do going in,” says Dr. Pereira. “Some of the steps that could be trickier were anticipated, and knowing what to expect gave us added confidence to ensure the procedure’s success.” The importance of this type of clinical advancement is closely connected to the success of endovascular procedures for stroke treatment over the past 10 years. With modern techniques, dedicated stroke treatment centres are able to half the mortality rate of stroke patients, and double the rate of independent living in successful treatment outcomes.
Dr. Krings, Division Head of Neuroradiology, JDMI and Site Chief, Medical Imaging, Toronto Western Hospital says, “Theoretically with this type of treatment, will we be able to bring the necessary clinical expertise to the patient, instead of bringing the patient to our hospital.” “We believe that this is the first step towards performing remote neuro interventional procedures, especially in rural areas of Canada where there is limited access to timely ischemic stroke care.” As next steps, JDMI’s Neuro Interventional Radiology team looks to test remote procedures on 3D – models through local connections between hospitals and develop an established protocol for true remote interventional procedures. “Stroke is a disease where time is essential,” says Dr. Pereira. “If we can reduce the time we spend transferring patients, and begin to offer remote access for stroke treatment anywhere, we can bring a new level of expert care to patients H in need.” ■
Roger Boyle is a Communications Specialist at University Health Network. 14 HOSPITAL NEWS DECEMBER 2019
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ETHICS
Auld Lang Syne: Ethics and the year in review By Ann Munro Heesters simple and not especially melodic folk song, popularized by the poet Robert Burns, is trotted out every New Year’s Eve by people all over the world. “Auld Lang Syne” (which may be loosely translated as long, long, ago) seems to speak to something important and universal, whatever our cultural backgrounds: that is, our need to take stock of the events that have been significant for us. Twelve months might be too great or too short an interval (depending on what we’ve been facing personally and professionally), but it feels right to reflect, engage in a little sense-making, and, for some folks at least, to form some resolutions about
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how we intend to face the challenges that lie ahead. Perhaps because my birthday is New Year’s Eve (or Hogmanay for those who observe that tradition), I’ve tended to take the year’s end more seriously than most. It’s sobering to face one’s mortality, annually, at the stroke of midnight on one of the darkest days of winter. This year I have the additional pleasure, and pain, of reflecting on the year in healthcare ethics for the December issue of Hospital News, and I notice – as doubtless have many of you – that what appear to be novel concerns really are perennial ones. We are hearing an awful lot about privacy in the digital age, and how Big Data and Machine Learning
will transform medicine. We are also hearing that healthcare ethics must contemplate what it means to be attentive to the needs of our patients – and of our public – outside the walls of our hospitals and other traditional healthcare settings. The big ethical questions are complex, and interconnected, and oblige us to learn to collaborate with new and more diverse partners. Patients, professionals, community, and industry partners need to learn how to work together to decide what our priorities ought to be and how best to achieve the aims we seek. Daily, we hear sobering news reports that underscore the importance of the social determinants of health, and we have come to understand that there
are no quick fixes for the damaging and stubborn impacts of economic instability, stigma, social isolation, and racial (and other) biases to name but a few of factors that affect our abilities to live healthy and fulfilling lives. Superficially, at least, some aspects of these challenges are novel. Although scientific advancement has always required efforts to gather reliable evidence, the appetite for information has never been greater. The promise of machine learning can only be realized if curiosity is fed with vast oceans of data. Health researchers, often in collaboration with industry-partners, are using computational tools to find relationships between variables that we never before imagined relevant. Continued on page 17
Ann Munro Heesters is Director of Bioethics, University Health Network; Adjunct Lecturer, Dalla Lana School of Public Health; U of T Member, Joint Centre for Bioethics, University of Toronto.
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FROM THE CEO’S DESK
United in purpose
By Dr. Gillian Kernaghan uilding success is hard enough, but how do organizations sustain success in the long run? This is a question St. Joseph’s Health Care London, and countless other health care organizations, have been contemplating for decades. In a health care setting, success is defined by many things but patient satisfaction should always be at the forefront. I was delighted this fall when our organization once again received “Exemplary Standing” from Accreditation Canada. This marks the third time straight for St. Joseph’s, which extends our exemplary standing to a remarkable 12 years – a feat only made possible by sustaining excellence. Reaching a target is only the first step in creating lasting change. Sustaining that change requires much more. It takes endurance, effort and the ability to look past the initial goal. It takes commitment to new processes, approaches and ongoing refinement. Imagine if health care was a sport. Focusing only on the scoreboard wouldn’t result in consistent wins. It takes every day improvement by concentrating on teamwork, discipline, planning, and practice to ensure ongoing progress. It would require understanding that ultimate victory comes with continuous long-lasting improvement. Achieving an exemplary standing “three-peat,” has provided the opportunity to reflect on St. Joseph’s history in setting aggressive targets, working hard to achieve them, and equally as hard to sustain them.
on a corporate scorecard. These targets are increased each year until they reach a sustainable goal. Once the ultimate goal has been achieved we keep it on our corporate score card for four quarters and watch it for another year to ensure it is hardwired in the organization. If it degrades we discover why, and if required bring it back on as a corporate priority. We never lose sight of it until it is firmly rooted in the work we do.
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HOW CAN WE DO BETTER TOMORROW?
So how can organizations sustain success, change and outcomes? I believe it starts with accountability and the core values of an organization. Is your corporate culture one of “always”? Always asking ‘how can we do
UNITED IN PURPOSE
Dr. Gillian Kernaghan this better tomorrow?’ Always striving to improve. It’s not just about setting goals – but setting progressively aggressive goals. As a CEO, or as a head coach if we go back to the sports analogy, I have to set the playing field for success. It’s my job to inspire and establish the shared vision of our organization, making sure the mission and values are embedded in our work. The mission, vision and values then drive our corporate culture, and leaders transform that culture into practice and performance. In setting ambitious goals it’s imperative to be transparent. As leaders we need to walk the talk. With leaders setting the example of excellence and
holding teams accountable, the result is quality performance.
STRATEGIC GOALS AND METRICS
At. St. Joseph’s, three-year aspirational goals and metrics are established. These goals become our compass, setting the direction for the organization. The metrics focus on several areas, including: • Partnerships and engagement • Academic achievements • Patient experience and outcomes • Quality and safety • Staff, physician, volunteer and family engagement Every year corporate goals and targets are established and are included
When the vision and mission are clear, there is understanding in why we do what we do. I can say without a doubt that staff, physicians and volunteers at St. Joseph’s understand and live our vision to “Earn complete confidence in the care we provide and make a lasting difference in the quest to live fully.” During our accreditation process the surveyors noted that St. Joseph’s is “an organization united in purpose.” They could see tangible evidence of our focus on every patient/ every encounter/every time, and that we don’t compromise on quality and safety – a key principal in our strategic plan. Part of being united in purpose is our work with others. This is a key to success and necessary in sustaining any goal in health care. Our endless aim of earning the complete confidence of our patients can only be achieved through collaboration with our partners, patients and families. Their unique perspectives are invaluable in shared decision making. The Premier’s Council’s report, A Healthy Ontario: Building a Sustainable Health Care System recognizes the need to focus on putting patients at the centre of their care and supporting them through all interactions. It’s clearly recognized that listening to patients, families and partners is vital to the sustained success of health care delivery. Continued on page 17
Dr. Gillian Kernaghan is President and CEO at St. Joseph’s Health Care London. 16 HOSPITAL NEWS DECEMBER 2019
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ETHICS
CEO’s desk Continued from page 16
WE ARE IN THIS TOGETHER
An exemplary standing “three-peat” is a testament to the tremendous dedication of our staff, physicians and volunteers. I also believe strongly that we must reach beyond our walls to sustain success. We have a responsibly to contribute to system-wide success, and the advancement of the health care system as a whole. What health care organizations are doing right should to be shared on a provincial level. We can be successful together, within our own organizations and regions and as part of the broader health care system, through transparent goals that are values-driven, leveraging leadership excellence, and focusing on progression – not just today’s achievement. When this is realized, the scoreboard becomes simply a number and continually striving for H excellence becomes the end game. ■
Ethics and the year in review Continued from page 15
The results of our usual tests and monitoring systems are being supplemented with so-called patient-generated data and now individual patients’ online purchasing habits, social media interactions, and outputs from apps and fitness trackers, all can be combined to predict and alter health outcomes. This is heady stuff, where it can seem that everyday life is catching up with science fiction, and we can be forgiven if we believe that we are edging toward a future where real-life Dr McCoys will be able to rely on devices akin to Star Trek’s all-purpose tricorder which can scan for disease in a cost-effective, non-invasive, instantaneous manner. The enduring appeal of science fiction, however, is owing to its ability to find and unpack eternal, all-too human, questions in what appear to be novel circumstances. In addi-
tion to geeky novelty, the writers of that genre have offered us a variety of ethical insights including an appreciation of the fact that individuals’ assessments of value and of risk may differ greatly. They also provide glimpses of the dangers that great power-differentials can present, and prompt meditations on the tensions between autonomy and community, and the unintended consequences (including the loss of privacy) that can follow from the naive pursuit of knowledge. Once we recognize that these, and other, ethical questions are timeless ones we can approach current challenges with greater confidence and humility (even though these descriptors may seem to pull us in opposite directions). If we are to harness the data now at our disposal, we need to include voices that we don’t often hear, and we are obliged to think
hard about how the most vulnerable among us can be part of conversations about the priorities of our healthcare agencies and our research agendas; and, if technology holds the potential for great good, we can’t ignore questions about how best to mitigate or eliminate the factors that result in an uneven distribution of benefits and burdens. Ethics, in every culture at every time, has been occupied with questions like these. Let’s explore the promises that our new technologies and tools offer (including the tools essential to what Eric Topol calls Deep Medicine), but let’s also devote energy and enthusiasm for the asking the deepest questions like, What do we owe to one another? and, What are we sacrificing in the pursuit of innovation? Scotty can’t beam us up; after all, this brave new world is the only one H we’ve got. ■
COMM
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SAFE MEDICATION
Unintentional medication incidents when using combination drug products By Allen Chiu and Certina Ho hile the intrinsic nature of healthcare is to do good, the opposite may unintentionally occur. For example, something as simple as combining two pills as one in order to provide convenience and improve adherence in patients can still have the potential to cause patient harm. The following medication incident was anonymously reported to the Institute for Safe Medication Practices Canada (ISMP Canada): “Patient was admitted to emergency with confusion and hypotension. It was
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later found out that the patient took both metformin 1000 mg twice daily and a combination metformin/sitagliptin 1000/50 mg tablet twice daily. Several weeks ago, it was suggested that the patient switched to a combination pill [metformin/sitagliptin 1000/50 mg], but the old medication [metformin 1000 mg] was not discontinued.”* *Note: The maximum dose of metformin is 2550 mg per day. In this case, the patient has taken a total of metformin 4000 mg per day due to duplicate therapy.
Combination drugs or fixed-dose combinations, for the purpose of this article, refer to a medication that contains more than one active ingredient. They are also sometimes referred to as “combo pills” or “polypills”. Using combination drug products can potentially reduce pill burden and may increase patient adherence, leading to better patient outcomes. This strategy may also reduce the financial cost to the patient. Fixed-dose combinations are most commonly seen in anti-hypertensives and anti-hypergly-
cemics, but they can also be found in other therapeutic categories, such as, glaucoma eye drops and anti-retrovirals, etc. A 2015 report of prescription data by the Canadian Healthcare Network showed that combination medications were the top two most commonly prescribed within the therapeutic class of cardiovascular drugs. Table 1 provides some examples of these combination drug products. However, as seen in the above medication incident, using combination drugs can also inadvertently
ICU national research network: First of its kind in Canada By Steven Gallagher Niagara Health physician is leading the launch of a national network to support the growth of research in Intensive Care Units at community hospitals in Canada. The Canadian Community ICU Research Network, which held its inaugural meeting on Nov. 11 in Toronto, is the brainchild of Dr. Jennifer Tsang, Niagara Health’s Research Lead and Intensivist. Dr. Tsang worked closely with Dr. Alexandra Binnie, an Intensivist at William Osler Health System, to see her idea come to fruition. “The goal of the network, a first of its kind in Canada, is to develop strategies for building and sustaining research programs in community hospitals,” says Dr. Tsang, who also credited Niagara Health Intensivist Dr. Erick Duan for his collaboration in developing the network. “Research has a profound impact on the health and wellbeing of the people who live in our communities. Health research provides important information about disease trends and risk factors, outcomes
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Members of the Intensive Care Unit at Niagara Health who conduct research. of treatment and patterns of care, to name a few.” More than 65 per cent of Canadian patients receive care in community hospitals, but, historically, most medical research has been conducted in academic hospitals in larger centres. “If you’re only studying patients in the academic centres, the results are not applicable to everyone,” says Dr. Tsang. Representatives from about 20 hospitals, universities and research organizations from four provinces – Ontario,
Quebec, Alberta and Manitoba – attended the inaugural meeting, which was sponsored by Niagara Health and Niagara Health Foundation. The meeting focused on describing the current research landscape in community ICUs, discussing strategies to build research capacity in community ICUs and defining the structure and scope of the research network. Niagara Health, a regional healthcare provider with multiple sites, has been a leader when it comes to research in a community hospital set-
ting, working closely with its academic partners. Niagara Health established a dedicated Research Office in 2015 to strengthen its research and academic partnerships and set out to conduct research that would inform care, inspire innovation and create environments of collaborative learning. Research and clinical trials are taking place in several Niagara Health departments/divisions, including the Intensive Care Unit, Oncology, Urology, Cardiology and Emergency Medicine. Dr. Tsang and Paige Gehrke, a Registered Nurse in the ICU at Niagara Health’s St. Catharines Site, recently had their work published in the prestigious Canadian Medical Association Journal (September 3, 2019 issue), examining the impact of research activity in community health settings. They were part of a team of clinicians who suggest that increased involvement in research could offer more capacity for national research, expedite knowledge translation, increase staff engagement, opportunities for continuing education and enhanced clinician career satisfaction, H among many other benefits. ■
Steven Gallagher is a Communications Specialist at Niagara Health. 18 HOSPITAL NEWS DECEMBER 2019
www.hospitalnews.com
SAFE MEDICATION
cause patient harm. This may not be an isolated case. A 2018 study on Irish prescription claims reported that therapeutic duplication errors were more likely in anti-hypertensive fixed-dose combinations compared to their individual components. While the above incident involved a different class of medications (i.e. anti-hyperglycemics), it was a therapeutic duplication error of metformin. While more research may be warranted on this topic, Table 2 offers some suggestions that may potentially decrease the risk of these incidents. In conclusion, while switching patients from single to combination drugs can have many benefits, healthcare practitioners should be aware of the potential risks H associated as well. ■ Allen Chiu is a PharmD Student at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is a Project Lead at the Institute for Safe Medication Practices Canada (ISMP Canada).
Combination Drug Product
Individual Active Ingredients
Therapeutic Class
Janumet® / Janumet® XR
sitagliptin and metformin
Anti-hyperglycemic
Caduet® (generics available)
amlodipine and atorvastatin
Anti-hypertensive and antihyperlipidemic
Atacand Plus® (generics available)
candesartan and hydrochlorothiazide
Anti-hypertensive
Altace HCT®
ramipril and hydrochlorothiazide
Anti-hypertensive
Vimovo®
naproxen and esomeprazole
Analgesic and gastroprotection
Truvada®
emtricitabine and tenofovir
Anti-retroviral
Table 1. Examples of Combination Drugs or Fixed-Dose Combinations (Note: This is not a comprehensive list.)
Suggestions
Comments
Technology e.g. Computerized Clinical Decision Support (CCDS)
Differentiate between duplicate drug therapy alerts versus duplicate therapeutic class alerts from the CCDS. Discontinue inactive medications on patient profile to avoid unnecessary duplicate therapy alerts from the CCDS.
Communication and Patient Education
Counsel patients on new medications when switching to combination drugs or fixeddose combinations. Ensure patients understand that the new fixed-dose combination replaces which of their old medications. Ask patients to bring back old medications (i.e. inactive medications on their profile) to the pharmacy for disposal to prevent any confusion.
Conduct medication reviews with patients periodically or during changes of their medication therapy. This may help patients better understand their medication Medication Review regimen and update patient profiles at the same time to prevent unnecessary alerts from the CCDS. Table 2. Suggestions to Prevent Therapeutic Duplication Errors Associated with Combination Drugs or Fixed-Dose Combinations
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SPECIAL FOCUS: RADIOLOGY
Excessive wait times for medical imaging hurts Canadians in more ways than one By Dr. Michael Barry atients know too well that waiting for diagnostic imaging can be emotionally draining for them as well as for their families. Everyone knows someone who is waiting for care and may miss work but how much does it cost patients and the economy? Reasonable access to medical imaging procedures is a growing problem for Canadians. Having to wait months for MRIs and CTs not only negatively impacts health outcomes but also costs the healthcare system billions of dollars each year. The Canadian Institute for Health Information as well as the Commonwealth Fund have documented Canada’s below-average performance on wait times. Sadly, this is not new.
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As our population increases and with a growing ageing population, demand for diagnostic imaging exams will rise. The current stock of imaging equipment is aging and making matters worse, the number of new machines being added is at a 20-year low. It is estimated that 27 per cent of medical imaging equipment is more than 10 years old, which is significantly below international standards of equipment distribution referenced by the Conference Board in the Value of Radiology Part II report. It is recommended that 60 per cent of medical imaging equipment should be less than five years old. Canada is currently not meeting this standard. Canadians understand that this is a problem and have indicated their
WE NEED TO ENSURE THAT PATIENTS AND PROVIDERS HAVE ACCESS TO MORE EFFICIENT TECHNOLOGIES THAT CAN BETTER DIAGNOSE ILLNESS AND TREAT DISEASE. According to a recent report (June 2019) published by the Conference Board of Canada, excessive waiting (beyond 30 days) for MRI and CT examinations cost the economy $3.54 billion in 2018. In addition, these wait times keep over 380,000 Canadians from work resulting in a loss of $430 million in tax revenue annually.
support for additional investment in medical imaging equipment. A poll conducted by Nanos Research revealed that seven in 10 Canadians say that Canada should spend tax dollars to have more current medical imaging equipment. We need to ensure that patients and providers have access to more
CAR Leadership on Parliament Hill, May 2019. efficient technologies that can better diagnose illness and treat disease. By providing proper access to medical imaging tests, patients can be diagnosed and treated sooner resulting in improved health outcomes, less time off work and substantial cost savings to the economy. What can governments do to respond to this pressure? It’s clear that the capacity for imaging is an issue. So, improving access to more medical imaging equipment would help. In 2004, the federal government, through a transfer to the provinces, did just that, investing close $2.5 billion dollars in new medical imaging equipment. These investments have been made
before and can be made again. In fact, the Conservative Party of Canada made a pledge to invest $1.5 billion in medical imaging equipment over four years as one of their key priorities leading up to the 2019 Federal Election. Patients have an opportunity to make their voices heard. Now is the time to invest in Canadians. By allocating $1.5 billion for medical imaging equipment to the provincial governments over four years, wait times would be reduced and patients would receive the care they deserve. Less waiting, less anxiety, better care and greater economic output would seem to be both right and proper policies for H Canada. ■
Dr. Michael Barry is a Radiologist, Saint John, New Brunswick and President, Canadian Association of Radiologists. 20 HOSPITAL NEWS DECEMBER 2019
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SPECIAL FOCUS: RADIOLOGY
$49 million federal investment in a Digital Health and Discovery Platform n May 23, 2019, in Montreal, Quebec, the Honourable Navdeep Bains, Minister of Innovation Science and Economic Development, announced that the government will invest up to $49 million in the Digital Health and Discovery Platform (DHDP). The DHDP is a network of partners, including the Canadian Association of Radiologists (CAR) that is led by the Terry Fox Research Institute (TFRI) and Imagia. Their purpose is to work together to establish a cutting-edge Canada-wide health data platform, which is patient-centric and upholds the highest standards for data, privacy, security and safety. The DHDP will greatly empower TFRI’s Marathon of Hope Cancer Centres network. For the first time, cancer centres and research institutes across the country are joining forces from coast-to-coast-to-coast to advance a
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world-leading, precision medicine cancer plan, a roadmap to cure cancer, to benefit all Canadians. The four-year project will leverage Imagia’s EVIDENS AI discovery platform and clinical collaboration ecosystem. The platform empowers clinical researchers from different pan-Canadian institutions to derive outcome-based insights from real-world evidence and collaborate on AI biomarkers and clinical decision support systems. The CAR is thrilled to be part of the DHDP network of leading radiologists and researchers and is looking forward to working to accelerate the development of new treatments to help identify cures for diseases. Radiologists and data scientists at institutions across Canada will be able to work within the research network to harness the power of medical imaging data sets and evidence to tackle proj-
CAR was present at Minister Bains’ announcement related to AI funding, June 2019. ects using the platform developed and honed by Imagia and other partners. The DHPD network will connect almost 100 partners across Canada, including health care institutions; small, medium-sized and large companies; universities and research foundations and all four major artificial intelligence (AI) research labs in Canada. The Canadian Heads of Academic Radiology (CHAR) are also key network partners,
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representing medical imaging departments at institutions across Canada. This funding announcement demonstrates a strong commitment on the part of the Federal government to invest in innovative health and bioscience research models, which will have a direct and meaningful impact on medical imaging research, the Canadian radiology community, and our ability to catalyze H improvements to patient care. ■
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DECEMBER 2019 HOSPITAL NEWS 21
SPECIAL FOCUS: RADIOLOGY
Dr. Brian Archer with his team.
Saint John radiologist helps revolutionize acute stroke management in New Brunswick By Helen Murphy ith a dedicated team of colleagues, Dr. Brian Archer has introduced endovascular stroke treatment for New Brunswick patients. In doing so, he has demonstrated what is possible for other small healthcare centres across Canada. In the vast majority of stroke cases, if patients seek treatment early enough, a clot-dissolving agent can save lives and give much higher quality of life. But with large clots, a dissolving agent alone does not yield good outcomes. For the past 10 years in New Brunswick, these patients have been referred to Dr. Brian Archer and his team at Saint John Regional Hospital (SJRH) for clot removal – the first non-university hospital in Canada to offer the procedure. “By being one of the first [Atlantic] Canadian doctors to offer clot retrieval, Dr. Archer has had an enormous effect on the health outcomes of
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countless New Brunswickers,” says fellow SJRH radiologist John Swan, MD, FRCPC. Because the treatment is time-critical, Dr. Archer says it was imperative that this expertise was developed and offered in New Brunswick. “There is no time to fly patients out to a university hospital,” he explains.
For many of Dr. Archer’s patients, the results have been nothing short of amazing. He recalls a stroke victim who woke up in ICU after a successful clot-removal procedure and basically walked right back into his daily life. “Because of his quick recovery, I think he and his family probably feel that he really wasn’t that sick at all.” Jordan Kavanagh, MD, FRCPC, another radiologist at SJRH, says Dr. Archer is often called in for the most difficult cases. He gives the example of a 12-year-old girl with paralysis on one side of her body. Although the clot-removal procedure is rarely done in pediatric patients, after careful consultation with family and colleagues, it was decided that Dr. Archer and his colleague, John Whelan, MD, FRCPC, would take it on. “The procedure was a complete success,” says Dr. Kavanagh. Dr. Archer is well-known for innovating procedures for patients with challenging conditions.
“As an example, he and colleague Darren Ferguson, MD, FRCPC, were able to embolize a crossbow injury to the liver by using the embedded projectile as a vascular access sheath,” recalls Dr. Swan. “To most of us, that would be the case of a lifetime. To Dr. Archer, that is a normal Tuesday evening.” While colleagues call him a role model and the kind of physician other physicians turn to for advice and assistance in difficult times, he downplays this praise. “Really, none of us want awards,” says Dr. Archer, who characterizes himself as average and attributes his professional success to good teamwork and an element of luck. “I have had grateful patients give me a hug and that is more than enough.” Dr. Brian Archer was selected as is this year’s recipient of the Prix d’excellence – Specialist of the Year award for Atlantic Canada from the Royal College of Physicians and SurH geons of Canada. ■
Helen Murphy, The Royal College of Physicians and Surgeons of Canada. This article is reprinted with permission from the Royal College of Physicians and Surgeons of Canada. 22 HOSPITAL NEWS DECEMBER 2019
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SPECIAL FOCUS: RADIOLOGY
Elevating education through a world-class e-learning platform By Julia Niles hysicians need CPD to maintain sharp skills but don’t always have the time to attend conferences, so the Canadian Association of Radiologists developed an easy to use online learning system called RAD Academy – the first of its kind in specialty medicine in Canada. In September 2018, the CAR launched a learning management system, RAD Academy to meet the educational needs of its members as well as facilitate compliance with their certification requirements. RAD Academy elevates the CAR’s CPD offerings and improves the overall learning experience by providing radiologists with access to world-class research and innovation in radiology and eLearning opportunities. Key features of RAD Academy: • The new home for CAR Journal’s Insights for Imaging program allowing radiologists to access sought after section 3 maintenance of certification learning credits • A CPD Dashboard that provides members with a high-level look at what matters most, including new initiatives, their current CPD activities, calendar, notifications and the course catalogue. • Multiple search options which make it easy to find the exact CPD activity or resource. • Transcripts and certificates accessed directly from the personalized transcripts page, as well as the ability to keep track of CanMEDS role competencies. This feature allows users to identify which roles they need to focus on. • The ability to evaluate and comment on CPD activities and see feedback others have shared. • A dedicated Resident and Fellow Portal for radiologists-in-training, which features resident-specific re-
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RAD ACADEMY ALLOWS ME TO ACCESS CPD CREDITS ON MY OWN TIME FROM ANYWHERE WHEN I HAVE A MINUTE. IT ALSO TRACKS ALL MY CREDITS IN ONE PLACE FOR ME. --DR. CAROLYN FLEGG, CLINICAL HEAD FOR THE DEPARTMENT OF MEDICAL IMAGING OF THE SASKATOON HEALTH REGION search and resources. RAD Academy provides a national platform for the medical student network and their radiology interest groups (RIG) and is a repository for radiology research projects (modules) that are currently happening in tandem across the country.
The CAR’s RAD Academy continues to expand its offerings. With new activities being added consistently, radiologists have exclusive access to innovative eLearning opportunities from global leaders in radiology on emerging trends and technologies, tips and techniques to improve patient care as
well as enhance their knowledge and competencies across the CanMEDS framework. The CAR is dedicated to supporting lifelong learning in the pursuit of helping radiologists stay at the cutting edge of medical imaging. With currently over 50 available offerings, RAD Academy presents a variety of CPD activities including an accredited journal-based self-assessment program and interactive modules covering a gamut of topics in diagnostic and therapeutic medical imaging. Raising the bar for professional development by enhancing medical education, experience RAD Academy. *RAD Academy is available excluH sively to CAR members. ■
Julia Niles is a Learning and Development Specialist at The Canadian Association of Radiologists. www.hospitalnews.com
DECEMBER 2019 HOSPITAL NEWS 23
NEWS
Using smart technologies to make a meaningful impact on patient care By Christina Cindric t Mackenzie Health, staff across the organization have worked hard to integrate innovative, smart health care technologies into the way care is delivered to patients. The approach to digital health has resulted in the organization becoming the first Canadian acute care hospital to receive the highest certification for electronic medical record adoption – HIMSS EMRAM Stage 7. This year, Mackenzie Health was also named a recipient of the HIMSS Nicholas E. Davies Award of Excellence for the thoughtful application of health information and technology to substantially improve clinical care delivery, patient outcomes and population health. Mackenzie Health’s adoption of smart technologies and approach to delivering care has made a meaningful impact on the lives of patients in a number of ways. Results include decreasing the amount of time it takes to treat stroke patients and those suffering from chronic obstructive pulmonary disease (COPD) and reducing instances of hospital acquired infections.
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STROKE PATIENTS ARE TREATED IN HALF THE TIME
During a stroke, every second makes a difference in a patient’s recovery. The Mackenzie Health clinical team adjusted electronic workflows and protocols to streamline key areas of the patient journey. Now, patients who receive care at the York Region District Stroke Centre at Mackenzie Health receive life-saving medication 50 per cent faster, significantly improving their chances of recovery. Mackenzie Health is the only hospital in Ontario’s York Region to
provide the clot-busting drug tissue plasminogen activator (tPA), which breaks apart the clot to help restore blood flow to the brain to help reduce the damage of a stroke. In 2016, Mackenzie Health’s median time from when the patient arrived at the hospital to when tPA was administered was 53.5 minutes. Now in 2019, it’s 27 minutes – three minutes faster than the provincial target. Earlier treatment for those experiencing a stroke has also contributed to patients going home sooner with less disability.
COPD PATIENTS ARE DISCHARGED HOME SOONER
COPD affects 750,000 Canadians and is a progressive lung disease that blocks airflow and interferes with normal breathing. Patients with this condition often have high hospital needs and are admitted through the emergency department. To streamline care, clinical teams at Mackenzie Health developed a COPD tool based on best practices that they embedded within the electronic medical record to standardize care for patients. They also introduced electronic prompts and digital documentation to synchronize workflows and further support care teams. Being able to access real-time data helps to better monitor, plan and implement clinical care improvements that have led to improved recovery and patient outcomes. Using the COPD tool has resulted in earlier treatment while shortening the length of hospital stay by more than two days for these patients. It has also allowed Mackenzie Health to care for more patients with the same resources.
Mackenzie Health has been named a recipient of the HIMSS Nicholas E. Davies Award of Excellence for the thoughtful application of health information and technology to substantially improve clinical care delivery, patient outcomes and population health.
REDUCED HOSPITAL ACQUIRED INFECTIONS
Approximately 38,000 instances of hospital-acquired C. difficile are reported across Canada annually. Mackenzie Health used a multi-disciplinary team approach to help decrease instances of the infection. Working collaboratively across departments, staff leveraged information technology tools to optimize workflows, which resulted in decreased antibiotic usage, reduced time in isolation and improved environmental cleaning. Since implementation of these workflows in the electronic medical
record in 2017, Mackenzie Health has decreased antimicrobial usage by 22 per cent and decreased hospital-acquired C. difficile infections by 47 per cent. These advances are only a few examples that demonstrate that health care innovation and improved patient care, recovery and experience go hand in hand. People at Mackenzie Health are always looking for new and innovative ways to improve care delivery, and are excited to be part of Canada’s first smart hospital when the new Mackenzie Vaughan H Hospital opens. ■
Christina Cindric is a Senior Communications Consultant at Mackenzie Health. 24 HOSPITAL NEWS DECEMBER 2019
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NEWS
Students participating in Runnymede Healthcare Centre’s intergenerational program helped assemble wheelchair accessible flower beds for patients to use. Gardening can increase patients’ social interaction and influence their engagement with therapy.
Cultivating an outstanding patient experience By Michael Oreskovich hronic illness and stress sometimes associated with a hospital stay negatively impacts quality of life and can even affect a patient’s willingness to participate in treatment. By incorporating gardening into patients’ activation therapy sessions, Runnymede Healthcare Centre has developed an innovative way to enhance the patient experience and address this barrier. With support from the hospital’s activation therapy team, patients help plant seedlings in a vegetable garden in the open-air courtyards on the hospital’s second floor. They regularly tend to the plants’ growth over the summer by watering, weeding and turning the soil. When autumn comes they help harvest the vegetables, which include cucumbers, tomatoes and peppers. The therapeutic benefits of the gardening sessions are many. In addition to supporting the exercise of fine motor skills in patients’ hands, the activity increases social interaction, which can influence a patient’s engagement with therapy.
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“During a hospital stay, patients sometimes become socially isolated and withdrawn from their own therapy and recovery,” said Sarah King, manager of activation and volunteer services. “For patients at risk of social isolation, we find that gardening is a way of connecting them with others, which in turn improves their engagement with therapy.” It connects patients to the community, too. All produce harvested at Runnymede is donated to a community shelter called Sistering, which was chosen with patients’ input. “Many say that contributing to their community in this way gives them a greater sense of purpose while in hospital,” said King. “It fulfills their need to be nurturing and supportive at a time when they might be feeling vulnerable.” The gardening sessions are a great success, but when some patients told the hospital they were unable to participate due to their disability, Runnymede worked to find a solution. It responded in the summer of 2019 by building raised garden beds at the hospital, which are highly accessible.
Patients were involved in the planning of the raised garden beds, providing key insights into what needed to be considered in their design. In addition to improved wheelchair accessibility, they asked for the garden beds to be mobile so they could be brought inside for year-round use. The garden beds were also designed to be portable enough to go right into patients’ rooms, provided there are no safety risks. Construction of the raised garden beds was supported by the hospital’s partnership with Swansea Public School. Students from the school have been involved in intergenerational programming with Runnymede’s senior patients for years, and the project was identified as an enriching opportunity for kids in their STEM (science, technology, engineering and math) program. According to King, it was a perfect fit. “The students in the STEM program benefitted by working on the garden beds alongside our patients and maintenance staff,” she said. ”It
was wonderful to see a group of young students support our senior patients, who were enthusiastic about sharing their knowledge and experience with a younger generation.” The flowers in the raised garden beds are now tended by patients with the help of activation staff and children who continue to take part in the hospital’s monthly intergenerational program. The activation team is still in the early stages of exploring the garden beds’ potential to enhance the patient experience. Providing patients with enhanced access to hospital garden spaces is an innovative way of strengthening the patient experience at Runnymede. “By involving patients in our decision-making processes, we’ve expanded the success of our gardening sessions so that as many patients as possible can benefit,” King says. “We believe that it’s an excellent example of how our hospital finds new ways to enrich quality of life during a hospital stay and improve patients’ outlook on H their treatment and recovery.” ■
Michael Oreskovich is a Communications Specialist at Runnymede Healthcare Centre. www.hospitalnews.com
DECEMBER 2019 HOSPITAL NEWS 25
From senior care to pharma,
LONG-TERM CARE NEWS
new speech-analyzer tool addresses gaps, meets needs By Dianne Daniel t begins with small mistakes. People forget their medication, miss an appointment or have trouble managing their diabetes. Eventually the errors compound and for many older adults, even slight cognitive impairment leads to a negative health outcome. This is the scenario Winterlight Labs is aiming to prevent with its newest pilot project. Partnering with VHA Home HealthCare, the company is testing its proprietary natural speech analyzer with 50 Ontario seniors throughout 2019. The goal is to refine the tool’s effectiveness as a clinical decision support tool.
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“We’re addressing a gap in the market,” says Winterlight Labs CEO Liam Kaufman. “When someone has a diagnosis of dementia, we know they need help managing their health care. But if they are only slightly cognitively impaired, they often fall through the cracks.” Winterlight Labs’ assessment is quick and easy to administer. Seniors spend two to four minutes describing pictures on an iPad. The platform uses artificial intelligence to extract and analyze more than 540 linguistic cues from their recorded speech, accurately distinguishing early signs of dementia from typical aging. If early cognitive impairment is detected, addition-
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al home care or other supports can be provided to pre-empt an adverse health event. The goal is to have a commercial product ready for the senior care market by early 2020, says Kaufman. In the meantime, the AGE-WELL-supported startup is making strong inroads in the pharmaceutical sector. “By using our platform in early validation studies, they’re able to see effects in a shorter time period on smaller populations,” explains Kaufman. In 2019, Winterlight Labs entered a collaboration with Janssen Pharmaceuticals Inc. to collect objective, quantifiable physiological and behavioural data – referred to as a digital biomarker – so that people with early-stage Alzheimer’s disease can be identified, before symptoms appear and when therapies have the most benefit. The company’s speech analyzer is also being used in several U.S. clinical trials to examine
the efficacy of new drug therapies to treat forms of dementia. “This is an important growth milestone for us, but we couldn’t have arrived here without the early-on investment from supporters like AGE-WELL,” says Kaufman, noting that some pharmaceutical deals have reached $500,000. AGE-WELL is a federally-funded Network of Centres of Excellence. In November 2019, Winterlight Labs announced that it had raised $5.6-million in series A funding in a round led by Hikma Ventures. Founded in 2015 by Kaufman, scientific advisor Dr. Frank Rudzicz and CTO Maria Yancheva, Winterlight Labs has grown to 12 full-time employees with more hires expected before the end of 2019. Operating out of JLABS in Toronto, the company is also supported by the Ontario Brain Institute, Ontario Centres of Excellence H and the University of Toronto.■
Dianne Daniel is a freelance writer based in Niagara Falls, Ont. www.hospitalnews.com
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LONG-TERM CARE NEWS
The dining room in long-term care By Dale Mayerson and Karen Thompson ll of the work of the Food and Nutrition Department comes together in the dining room. Ontario long term care homes (LTC) follow many regulations, as well as a much longer list of best practices, related to dining room service. The overriding goal is to encourage residents to eat and drink well in order to maintain or improve their nutritional status. There are many processes that need to be in place for this to happen and developing a comfortable environment and supporting resident enjoyment at mealtime is certainly worthy of attention. Eating meals is an activity that takes place three times each day making it a wonderful opportunity to really support a positive quality of life for residents. An organized LTC dining room atmosphere should be pleasant, with soft music playing in the background – ideal for residents to dine, chat and relax in comfort.
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The reality may be much noisier, with residents talking, dishes clanging, and staff communicating to each other across the dining room. The area may feel cluttered with walkers and extra chairs. Although this is not the perfect arrangement for optimal food intake, staff work hard to make the residents comfortable.
GETTING READY FOR THE MEAL
Residents need to be prepared for meal times. This includes being appropriately dressed, with glasses, dentures and hearing aids in place. They should be seated at their assigned seats, so there is no confusion about who sits where, and with congenial tablemates. Residents’ seating plan should be determined based on residents’ sociability and not based on the diet or food texture they are being served. The dining tables should be fully set with placemats or tablecloths, and
with cutlery and napkins, before residents enter the dining room. Certain food items, such as crackers or condiments, may be placed on the table just before residents enter. Some dining tables can be altered in height, to allow residents seated in higher or lower wheelchairs to eat comfortably at the dining table. Every resident should be comfortable and safely positioned for the meal. Residents who are not sitting with good posture may need to be assisted to a better seating position; residents in wheelchairs may benefit from being propped up with pillows for safe swallowing. Residents should be greeted and served by staff who take the time to check their names, diets, textures, food likes, dislikes, allergies and intolerances, before serving them. Any resident who requires an assistive device for dining should have the device at the table setting, clean and ready to be used.
DURING THE MEAL
Residents may be served a beverage at the start of the meal, with a choice of juice and water always available. Some homes place water at every table setting, in order to encourage residents to maintain hydration. Offering residents as much choice as possible in the dining room is an important philosophy in LTC and provides residents with autonomy over at least one aspect of their lives. The use of “show plates” helps resident to select which of the two meal choices is their preference. Show plates are pre-plated and are used to show residents what the meals actually look like. Residents are encouraged to mix and match from the two show plates if that is their preference. More recently, some homes take pictures of the two meal choices with an electronic tablet, and then show the pictures to the residents. This is a cost effective way to offer choice, since the show plates are
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LONG-TERM CARE NEWS discarded after being shown around the dining room. Meals are served table by table and course by course. This means that as much as possible, everyone at a table is served at the same time and is given adequate time to eat. The whole meal service should be allotted 45 to 60 minutes. Staff may use a “table rotation” schedule so that the same table is not always served last. Unless otherwise indicated in a resident’s plan of care, once a resident finishes a course, the dishes are removed and then the next course is served. As staff remove the dishes, they may discreetly scrape the leftovers from the plates at a predetermined location in the dining room. Some homes are now using rubber spatulas for this task, in order to reduce the noise from cutlery scraping against the dishes.
PROVIDING INDIVIDUAL ASSISTANCE
Residents require differing levels of assistance to eat. Some residents
may be fully independent, while others need encouragement or “cueing” to complete the courses. Still others may need partial or full assistance with eating. These needs must be clearly communicated to staff and respected. All staff should know who needs which level of assistance, and the meal should only be served when the person assisting is ready to assist the resident. Providing full feeding assistance to a resident may take a long time, especially if the resident has swallowing difficulties. Dining room staff share the duties to ensure that every resident gets the correct meal and the time and help they need to eat. All residents are encouraged to eat in the dining room for socializing and so they can be monitored, but some residents may require meals in their rooms temporarily or on an ongoing basis. These residents are also offered a choice of meal and then supervised when eating in their rooms to avoid choking or other incidents.
AN ORGANIZED LTC DINING ROOM ATMOSPHERE SHOULD BE PLEASANT, WITH SOFT MUSIC PLAYING IN THE BACKGROUND – IDEAL FOR RESIDENTS TO DINE, CHAT AND RELAX IN COMFORT THE PHYSICAL ENVIRONMENT
The physical dining room itself should contribute to the meal experience. The ceiling and walls should be clean, with no food splatter or debris. All lights should be in good working order. Clean windows and window ledges help to let in the sunlight and fresh air. Appropriate artwork and decorations are important to add to the ambience. Tables and chairs should be clean, including arm rests and spaces around chair cushions. Table legs also need attention. Wall colour, chair fabric and window coverings should be conducive to a relaxed environment. Floors
should be cleaned frequently and any debris picked up immediately for safety. Equipment in the area, such as dishwashers, refrigerators, coffee machines and juice dispensers should operate quietly, as should fans and air conditioners. The dining tables may have a bud vase or other small decoration. Any condiments on the table, such as salt and pepper shakers, are cleaned after every meal, to remove any food residue. A pleasant dining room ambience and organized service contribute to helping residents enjoy their meals. Residents eating and drinking in comfortable surroundings are more likely to really enjoy the best H LTC dining experience possible. ■
Dale Mayerson, BSc, RD, CDE, and Karen Thompson, BA Sc, RD are Registered Dietitians with extensive experience in Long-term care. They are co-authors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians in Canada.
NURSING PULSE
Paving the way for primary care R By Victoria Alarcon etired primary care RN Judie Surridge, 69, still remembers many of the patients and families she assisted during her nursing career. She recounts her experience helping a refugee in 2001 through her first pregnancy, providing the information she needed to navigate the immigration process. She recalls being a shoulder of support for a woman with Alzheimer’s, and helping the woman’s daughter provide care. “You have to really be interested in looking at the patient’s whole life, not just a particular problem they have,” Surridge says. The role of the primary care nurse is to be there from “birth to death,” she suggests, and that was one of the reasons she wanted to be a nurse in the first place. Surridge graduated in 1970 from Women’s College Hospital in Toron
THE ROLE OF THE PRIMARY CARE NURSE IS TO BE THERE FROM “BIRTH TO DEATH.
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The role of the primary care nurse is to be there from “birth to death, to. She began working at the same hospital as an RN on the medical-surgical unit after doing her last nursing placement there. She treated patients with diabetes and severe arthritis, as well as those recovering from heart attacks and strokes. She enjoyed her role, but wanted more. “(You) were very much following doctors’ orders,” she says of nursing at that time. After a decade in acute care, she decided to try primary care after her friend recommended it. In addition to the
change in focus, working straight days appealed to her. In 1980, Surridge made the shift to Women’s College Hospital’s Academic Family Health Team (FHT). She was surprised by the experience. “You (got to know) the patients on a very different (level),” she says. In acute care, nurses see patients when they are sick. At the clinic, she saw patients throughout their life. During her first few years with the team, Surridge worked with a doctor and a team of residents to administer blood tests, check blood pressure, and give allergy shots. She wanted to expand her practice to counsel patients and to
work more independently. She saw an opportunity in the 1990s, when funding for FHTs began to change. So too did physicians’ trust in the nurses, and Surridge was encouraged to take on more. “I could talk to patients about how they were managing their medications and give them advice,” she says, noting that up to that point, she wouldn’t have been allowed to talk to patients on the phone. As she continued in primary care through the 1990s and 2000s, she became more actively involved in RNAO’s advocacy work, and also in her nursing community to speak out for the role of primary care RNs. “There were a whole bunch of RNs working in the field and no one was seeing the value of what we could do,” she says. In 2006, Surridge became president of RNAO’s Family Practice
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When Journals are driven by profit, not evidence:
e RNs Nurses Interest Group (now Primary Care Nurses’ of Ontario (PCNO)), and set out to build better relationships with physicians. She worked with the Ontario Medical Association, Ontario College of Family Physicians, and the Canadian College of Family Physicians to recognize how primary care RNs might work more collaboratively with physicians. In 2008, Surridge helped create a nursing program at George Brown College called the Family Practice Nursing Program, a one-year post-graduate course to prepare RNs for primary care. It officially launched in 2011, but had to dissolve in 2015 due to low enrolment. Eight years ago, Surridge was asked to co-lead the Registered Nurses’ Association of Ontario (RNAO) Primary Solutions for Primary Care Task Force with RNAO CEO Doris Grinspun. The resulting report called for an expansion in the scope of practice for primary care RNs and RPNs. In 2015, Surridge retired after more than 45 years in nursing. She is still active as PCNO’s past-president, and is helping to organize its 2020 conference in Ottawa where nurses across the country will network and share their experiences in primary care. She says she wants to take a back-seat role and give younger nurses an opportunity to lead, but knows she will continue to advoH cate for primary care. ■ Victoria Alarcon is communications specialist/ co-ordinator for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. This article was originally published on RNJ.RNAO.ca and is reprinted with permission. www.hospitalnews.com
Dr. Kelly Cobey talks about predatory journals ou might not have heard of “predatory journals,” but you might be basing medical decisions on the flawed research they publish. This research is sometimes spread via online blogs and the media, putting anyone at risk of using sketchy science to inform a decision. There are thousands of predatory journals in existence. Many of them are medical journals. To help raise awareness of predatory medical journals, the problems they’re causing, and the potential solutions, CADTH recently invited Dr. Kelly Cobey to the CADTH Lecture Series. CADTH – an independent agency that finds, assesses, and summarizes research on drugs, medical devices, tests, and procedures – regularly invites prominent scholars and opinion leaders, such as Dr. Cobey, to its CADTH Lecture Series to share their perspectives on pressing issues facing health technology assessment and health care today. Dr. Cobey is an Investigator at the Ottawa Hospital Research Institute (OHRI) and serves as the institution’s Publications Officer, providing educational outreach on best practice in academic biomedical publishing. She is also actively involved in meta-research topics related to journalology. After attending her talk, CADTH Knowledge Mobilization officer Barbara Greenwood Dufour was able to chat with Dr. Cobey to find out more about predatory journals and their impact on health care and our health. CADTH: Thanks for taking the time to chat with me, Dr. Cobey. Would you briefly remind us of what predatory journals are? KC: Predatory journals use an open-access model of publishing. This model is used by legitimate journals – it gives readers free access over the internet, and research authors pay an article processing charge to have an article published. But the research must withstand a rigorous peer review process first to ensure it meets a high standard. The difference with predatory journals is that they don’t uphold any standards; they just want the ar-
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THERE ARE THOUSANDS OF PREDATORY JOURNALS IN EXISTENCE. MANY OF THEM ARE MEDICAL JOURNALS. ticle processing charges. Predatory journals seek profits at the expense of scholarship. CADTH: How do we know that these journals aren’t upholding best practice standards? KC: There have been at least 15 “sting studies” studies to verify that this is happening. Fake research was submitted to these journals – some of it is obvious nonsense – but it was published anyway. That’s how we know they’re not reviewing these articles. We’ve also surveyed researchers who have published in presumed predatory journals and asked them about their experience; many indicate their work received little or no peer review. CADTH: Why are they called “predatory” journals? Who is the “prey”? KC: Researchers are, but the term “predatory journal” is a bit of a misnomer because some seek these journals out on purpose to quickly increase the number of articles they’ve had published. But others don’t realize these aren’t legitimate journals. Getting published should be an endorsement of the value and rigour of your work; but when your work is published in a predatory journal, it’s tainted, and there’s little you can do afterward. My key advice is to researchers is to look for red flags; and you see any, find another journal; there are many legitimate ones. CADTH: How are clinicians exposed to predatory journal articles? KC: They use Google to find out about new research like the rest of us. It may be shocking to patients that their doctor is not all-knowing – that they’re unable to spot a junk research study. But learning how to assess research quality hasn’t been integral to their training – if they were trained prior to 2012, predatory publishing wouldn’t have been covered since it is a relatively new phenomenon.
CADTH: What can be done to stop predatory publishing? KC: It’s an issue that’s not going away without action. The public could pressure governments to conduct audits of the work they support, to ensure that funds are not being misallocated to support work shared in predatory journals. People can also refuse to enroll in clinical trials without assurances that the work won’t be shared irresponsibly. Another strategy is to increase public awareness and provide tools that anyone can use to vet research – a one-stop, web-based resource that will assess research with a few clicks. CADTH: You’re referring to a tool that your group at OHRI is developing? KC: Yes. We’re seeking funds to develop an online authenticator tool for research studies, which could be used by researchers, clinicians, and the public – anyone who wants to find out if a research study is legitimate or not. CADTH: It sounds like anyone could have a stake in this, including the general public. KC: My one take-away message is that we underestimate how a single science article can end up informing – or misinforming – a large group of people. Think about how quickly the “chocolate prevents x” or “chocolate causes y” studies spread. Every time a junk study is promoted and then debunked, the public’s perception of science is damaged. The general public needs to understand that they can’t take research at face value, and they need tools to understand and use science. For more information about the CADTH Lecture Series or to attend the next lecture in person or online you can visit www.cadth.ca and follow us on Twitter: @CADTH_ACMTS (look for the #CADTHtalks hashtag). You can H also follow Dr. Cobey at @KDCobey. ■
DECEMBER 2019 HOSPITAL NEWS 31
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