Hospital News February 2020 by Hospital News

Inside: From the CEO’s Desk | Evidence Matters | Safe Medication | Careers Wound Care

February 2020 Edition

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Contents February 2020 Edition

IN THIS ISSUE:

Extending the reach of geriatric medicine

14 ▲ Cover story: Possible dementia vaccine closer

▲ Active rehab speeds recovery

COLUMNS

▲ Nominate your Nursing Hero

▲ Special focus: Wound care

Editor’s Note ....................4 In brief .............................6 Evidence matters ...........12 Ethics .............................22 From the CEO’s desk .....24 Long-term care ...............24 Safe medication ............30

▲ Artificial intelligence to help prevent falls

26 www.hospitalnews.com

Mobilizing pendence independence

Be careful, Canada

Lessons from the Irish health care system By Steve Thomas e careful what you wish for, Canada. One way or the other, Canadian courts are about to take some key decisions about the role of private financing and practice in your healthcare system; the on-going Cambie trial in British Columbia is just the latest attempt to overturn fundamental components of publicly funded medicare. The decision of this trial will have ramifications for decades and for millions of people. So, what can international experience teach us? One particularly illuminating case is Ireland. In 1957, the Irish Republic decided to set up a voluntary health insurer owned by the state to take the pressure off the public system, allowing those who had the means to buy healthcare. It sounded reasonable. But sixty years later, private health insurance has taken off with almost half the population covered. This allows faster access to public care subsidized by the state and queue jumping of the very long waiting lists by the better off. Despite only accounting for 12 per cent of total health funds, private insurance in Ireland now drives access to hospital care – the tail that wags the dog. Private health insurance occupies a unique role in the Irish setting providing faster access to care in both public and private provider settings. However, it does not always cover hospital expenses and often covers a fraction or no cover for non-hospital care such as outpatient appointments with a specialist, GP visits or care from allied health professionals.

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Private health insurance in Ireland does not cover drugs costs, perhaps because there is already a government reimbursement threshold for households spending more than a fixed amount in a month. Moreover, the benefits of queue jumping only accrue to those who are able to afford private health insurance premiums – and there are also concerns about the affordability of private health insurance. Ireland has historically been way off the pace when it comes to delivering universal healthcare and it is therefore an outlier in Europe and has one of the highest proportions of national income spent on voluntary health insurers. The result is two tier access to acute care and only very average results in terms of health outcomes. (The other two countries with large voluntary health insurance sectors are France and Slovenia but their insurers cover co-payments and they do not allow faster access). Rather than helping the public sector out, private insurance may have contributed to the problems. It erodes solidarity giving the well-off a way out of engaging with the public sector and potentially aggravating underfunding by making the better off less happy to be taxed more for health. It also means that dual practice providers – those who work in both the public and private sectors – have an incentive to keep their public waiting lists long to boost their private practice. Private insurance also costs in terms of public subsidies and the need for regulation. Continued on page 7

Steve Thomas is the Director for the Centre for Health Policy and Management at Trinity College, Dublin, Ireland.

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Active Rehab speeds recovery for an active person By Michael Oreskovich obert Tatarek is a man on the move. A general contractor who loves biking, snowboarding and being outdoors, the 36-year-old works hard and plays hard. His active lifestyle took an unexpected turn when he was hit by a car and ended up in acute care. Fortunately, Runnymede Healthcare Centre’s Active Rehab program was there to put Robert on a speedy path to recovery. The accident happened while Robert was riding his bike in Toronto. After being struck by a car he was thrown from his bike and landed on a curb with a badly broken leg. Robert was taken into surgery in a nearby acute care hospital where a pin was inserted in his femur.

home so he could use his washroom independently. “Every day I could see progress, and as I got stronger and stronger I was inspired to push myself even harder with the exercises the physiotherapists gave me,” Robert says. “The occupational therapists helped me get ready to get back into my daily routine back home.” Within five days of his admission, Robert met all of his treatment goals and was ready for discharge. He no longer needed support from others to move, could stand on his own two feet and was able to get around with the support of a walker. What’s next for Robert? He’s excited to get home and start back at work, but he knows there’s still some work ahead of him. “After I leave Runnymede, it’s up to me to finish my recovery,” he says. “The team here has taught me a lot about how to maintain my strength and I’m very confident H about going back home.” ■

ACTIVE REHAB HELPS PATIENTS MOVE OUT OF ACUTE CARE TO RECEIVE TIMELY ACCESS TO TREATMENT. After the surgery, he was confined to a wheelchair, something Robert wasn’t used to. “I’m the kind of person who can’t sit still for five minutes,” he says. “This wasn’t something I ever expected to happen to me.” Robert couldn’t resume his life in the community after his stay in acute care. He needed treatment to build up his strength so he could safely return home, and the acute care hospital referred him to Runnymede’s Active Rehab program. Designed to support patients who can tolerate fast and intensive therapy, typically after injury or surgery, Active Rehab helps patients move out of acute care to receive timely access to treatment. The program enables www.hospitalnews.com

Active Rehab at Runnymede Healthcare Centre restored Robert Tatarek’s mobility after he was injured in a serious collision. patients to regain their abilities and provides them with the skills and understanding they need to return to the community when ready. When Robert arrived at Runnymede, he experienced severe pain and couldn’t stand or move independently. Although he was optimistic, he admitted to feeling anxious about the recovery journey ahead of him. “The main thing I thought about was how long it would take before I could get better,” he says. “Knowing there was a whole team here dedicated to getting me back to how I was before my injury made me feel very welcome and supported.” The most important goal for Robert was to restore his strength and balance so he could get out of his wheelchair. The exercises the physiotherapists guided him through helped with this and increased the range of motion in his leg. Robert also had to learn to adapt to new limitations that accompanied his injury. Runnymede’s occupational therapy team helped him modify

his everyday tasks so he could safely get out of bed, wash himself and get dressed on his own. The team also arranged for some modifications at

Michael Oreskovich is a communications specialistat Runnymede Healthcare Centre

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FEBRUARY 2020 HOSPITAL NEWS 5

IN BRIEF

Lower levels of lymphocyte blood cells may indicate

increased risk of death ower levels of lymphocyte blood cells – a condition called lymphopenia – could be an early warning for future illness, as low counts were associated with a 60 per cent increase in death from any cause, found a Danish study in CMAJ (Canadian Medical Association Journal). “Our study showed that participants with lymphopenia were at high risk of dying from any cause, regardless of any other risk factor for all-cause mortality including age,” writes Dr. Stig Bojesen, with coauthors. Lymphopenia is often detected during routine blood tests, and patients are not usually referred for fur-

THE LINK BETWEEN LYMPHOPENIA AND DEATH MAY BE BECAUSE OF REDUCED IMMUNE CAPACITY TO SURVIVE POTENTIALLY LETHAL DISEASES. ther investigation because the value of lymphopenia as a predictor of future health was not known. Researchers included 108,135 people of Danish descent aged 20–100 years who were enrolled in the Copenhagen General Population Study between 2003 and 2015. An incidental finding of a low lymphocyte count was associated with a 1.6-fold increase in

the risk of death from any cause and a 1.5- to 2.8-fold increased risk of death from cancer, cardiovascular disease, respiratory disease, infections and other causes. During the study period, a total of 10,372 people died. Older age was associated with decreasing lymphocyte counts. The link between lymphopenia and death may be because of reduced im-

Revolutionizing rare diseases E very four years, International Rare Disease Day falls on that rarest of days, February 29th. This year 2020 is one of those rare years, and the Canadian rare disorders community has even more reasons to celebrate. Five years ago, the Canadian Organization for Rare Disorders launched Canada’s Rare Disease Strategy in collaboration with multiple stakeholders representing patient organizations, researchers, healthcare institutions and professionals, policy makers and industry. In 2020, we will update the strategy and action plans based on progress to date and identification of opportunities, priorities and synergies. While each rare disease affects only a small number of individuals, there are more than 7,000 rare diseases that together affect 1 in 12, or nearly 3 million Canadians. However, awareness, knowledge and treatment of most of these diseases are still limited and fragmented across the country. As a result, individuals face a host of extraordinary challenges, including misdiagnosis, unnecessary surgeries, social isolation,

6 HOSPITAL NEWS FEBRUARY 2020

financial hardship, lack of treatment options and early death. All of these challenges lead to increased morbidity, loss of life or poorer quality of life and increased costs to the family, the healthcare system and ultimately the Canadian economy. The Canadian Organization for Rare Disorders (CORD), as the umbrella organization for rare disease patients and patient organizations, brought together leaders from all sectors to develop Canada’s Rare Disease Strategy and launched it in Parliament in May 2015. The strategy identifies five core goals, specifically: • Improving Diagnosis • Providing for expert care and centres of excellence • Community support (including patient organizations) • Access to treatments • Support for research Importantly, in 2016, when the Ontario government agreed to develop a provincial rare disease plan, it used the CORD strategy as a planning base. One of the exciting propositions in the Ontario Rare Disease Framework was a “hub-and-spoke”

model, linking a designated rare disease “centre of excellence” to community-based service delivery sites. The strategy has served as the overarching framework for initiatives such as Genome Canada’s pilot project to provide exome (genome) sequencing for patients with undiagnosed rare diseases. The purpose is not only to deliver a diagnosis and potentially a course of treatment to patients like Ian but also to demonstrate the value of offering genome sequencing in the Canadian clinical setting. To improve access to treatment, the provincial/ territorial governments have proposed a supplementary review process, which would allow therapies to be provided to patients based on designated criteria with follow-up monitoring and evaluation of impact. And, of course, CORD was very excited to see the federal government’s commitment of $1 billion in the previous budget to set up a Rare Disease Drug Strategy (starting in 2022). And these steps will definitely help people get access to life-saving and life-altering mediH cines in a more timely fashion. ■

mune capacity to survive potentially lethal diseases. Lymphopenia could also indicate frailty which could lead to illness and death. The researchers hope their findings may help doctors identify atrisk people. “Using the absolute 2-year risks of all-cause mortality, physicians can identify highrisk individuals with lymphopenia (e.g., smokers older than 80 years) who might benefit from additional surveillance,” they write, although the benefits of such surveillance are not known. “Incidental lymphopenia and mortality: a prospective cohort study” was H published January 13, 2020. ■

AI-analyzed blood test can predict the progression of neurodegenerative disease valuating the effectiveness of therapies for neurodegenerative diseases is often difficult because each patient’s progression is different. A new study shows artificial intelligence (AI) analysis of blood samples can predict and explain disease progression, which could one day help doctors choose more appropriate and effective treatments for patients. Scientists at The Neuro (Montreal Neurological Institute-Hospital) of McGill University and the Ludmer Centre for Neuroinformatics and Mental Health used an AI algorithm to analyze the blood and post-mortem brain samples of 1969 patients with Alzheimer’s and Huntington’s disease. Their goal was to find molecular patterns specific to these diseases. The algorithm was able to detect how these patients’ genes expressed themselves in unique ways over decades. This offers the first long-term Continued on page 7

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IN BRIEF

Ontario hospitals

are national leaders in efficiency he Ontario Hospital Association (OHA) recently released a report, Ontario Hospitals: Leaders in Efficiency, which shows that while Ontario hospitals are leading the country in lean operational performance, the sector is now under significant strain, largely due to multiple years of funding restraint, demographic growth and a shortage of capacity in other sectors. “Ontario hospitals are fiscally responsible and have always strived to maintain access to high-quality care in the communities they serve,” says Anthony Dale, President and CEO of the OHA. “But given the extraordinary gains in efficiency made by Ontario hospitals in recent years, the expectation that additional major savings can be harvested simply isn’t realistic. Hospitals will always seek to innovate and improve, but for some organizations, continued access to high-quality hospital services is at risk.” The Report states that provincial government expenditure on hospitals

is lower in Ontario than in any other province at $1,494 per capita for 2019. If Ontario were to fund hospitals at the average rate per capita for all other provinces ($1,772), it would cost the province an additional $4 billion. This efficiency dividend frees up resources for the province to spend on other important priorities. Ontario hospitals also have the lowest hospitalization rate, shortest hospital stays and lowest cost per inpatient stay in the country. Today, Ontario has fewer acute hospital beds per 1,000 population than any other province and fewer beds than any other country tracked by the Organization of Economic Cooperation and Development (OECD). Hospitals are also caring for a record-high numbers of patients waiting for a more appropriate level of care at home or in the community. In September alone, there were 5,372 ALC patients, accounting for 17 per cent of hospital beds, waiting for a different level of care that was not available H when needed. ■

AI-analyzed blood test Continued from page 6

A NEW STUDY SHOWS ARTIFICIAL INTELLIGENCE (AI) ANALYSIS OF BLOOD SAMPLES CAN PREDICT AND EXPLAIN DISEASE PROGRESSION. view of molecular changes underlying neurodegeneration, an important accomplishment because neurodegenerative diseases develop over years. Previous studies of neurodegeneration often used static or “snapshot” data, and are therefore limited in how much they can reveal about the typically slow progression of disease. This study aimed to uncover the chronological information contained in large-scale data by covering decades of disease progression, revealing how changes in gene expression over that time are related to changes in the patient’s condition. Furthermore, the blood test detected 85 to 90 per cent of the top www.hospitalnews.com

Be careful, Canada Continued from page 4 As a potential way out, the Fine Gael Labour government of 2011 proposed Irish private insurers to be the basis of a Universal Health Insurance, modelled on the Dutch managed competition system. However, this policy cul-de-sac proved too expensive and too complex. It has now been abandoned for a more typical re-energizing of the public system in the guise of the “Sláintecare” policy.

IT IS STRIKING THAT AS IRELAND IS STRUGGLING TO LIMIT THE ROLE FOR TWO-TIER HEALTH CARE, CANADA SEEMS ON THE CUSP OF EMBRACING IT.

The core aims of Sláintecare are to establish a universal, single-tier health service where patients are treated solely on the basis of health need and funded through general taxation. This means a removal of private insurance funding from public hospitals (over six years) with waiting time guarantees backed up by increased accountability and information.

Nevertheless, the disentangling of the public and private systems is not an easy task; it will take careful planning, sequencing, coalition building and changing the public narrative about the nature of the health system. These are worthwhile challenges to take on in order to deliver a true, universal health care system for Ireland. The introduction of private health insurance in Ireland allowed a two-tier system to develop with long waiting lists in the public system and limited financial protection for households. It is striking that as Ireland is struggling to limit the role for two-tier health care, Canada seems on the cusp of embracing it. While Canada might be considering an expanded role for private health insurance, such a decision needs to be taken with sober judgement. It cannot be easily unwound. Private health insurance was initially introduced in Ireland to take some of the pressure off the government. However, its introduction has impeded a fair, efficient and integrated system and there has been substantial profiteering by smaller insurers since the liberalization. It has taken 60 years to develop a plan that will disentangle public and private financing in Ireland. Implementation will take another 10 years at least. It must be questioned whether Canada can afford such a lengthy and H difficult journey. ■

predictive molecular pathways that the test of post-mortem brain data did, showing a striking similarity between molecular alterations in both the brain and peripheral body. “This test could one day be used by doctors to evaluate patients and prescribe therapies tailored to their needs,” says Yasser Iturria-Medina, the study’s first author. “It could also be used in clinical trials to categorize patients and better determine how experimental drugs impact their predicted disease progression.” Iturria-Medina says his next steps will be testing these models in other diseases such as Parkinson’s disease H and amyotrophic lateral sclerosis. ■ FEBRUARY 2020 HOSPITAL NEWS 7

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Why HealthHub is tackling patient engagement, beginning at the bedside t’s no secret that hospitals are facing mounting pressures. While demands on the system are going up due to trends like an aging population, patient expectations and changing technology, hospital budgets are going down. Hospitals are struggling to keep up and the situation is only projected to get worse. In the face of these challenges, healthcare leaders are looking for better ways to optimize hospital operations and ensure optimal patient outcomes. The challenge, however, has been finding a solution that is sustainable, cost effective and future proof. At HealthHub, we think the solution lies in the patients themselves – through patient engagement. Patient engagement involves providing patients with access to the right information at the right time. It means connecting patients to their healthcare providers and systems. And, it means supporting patients along the way with the right tools, controls and entertainment to make their journey as seamless and as frictionless as possible. Although decades ago, it was thought that patients should be kept in the dark about their own health, we now know that when patients are engaged, everyone wins. In fact, when patients are enabled with the right information, they become better informed, more empowered, and more engaged in their own care – all of which lead to better health outcomes and a more efficient healthcare system. Engaged patients mean that doctors can do more doctoring, nurses can do more nursing and administrators can focus on delivering added value to the system. So, just how can we facilitate patient engagement? By bringing the hospital to the patient’s bedside. Of the 5.8 days the average Canadian patient stays in hospital, most of this time is spent alone, often watching a bedside TV. At HealthHub, we

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Table 1

recognized this as an opportunity for innovation. In fact, we’ve developed a new bedside terminal platform that replaces outdated TVs to deliver a powerful patient engagement solution. Our platform not only enables patients to be entertained through features like on-demand TV and Wi-Fi, but it also allows patients to stay engaged with family, friends, community, hospital and – most importantly – their own care, through a suite of patient engagement applications. By taking a patient-centered approach, we’re helping to bring the hospital to the bedside and transform the patient experience. HealthHub is investing significantly to improve the experience of the Canadian patient and, in 2019, launched our all-new myHealthHub

patient engagement platform, along with making other company changes (see table 1). What’s more is that our work doesn’t stop at the patient experience. The benefits of our bedside patient engagement platform extend beyond the patient and to healthcare providers. Let’s take one example. So many times, nurses report that they feel as if they’re the captain of their patient’s journey. In addition to providing caregiving and companionship, nurses are relied on to respond to a wide range of patient requests – dim the lights, order meals, adjust environmental controls and so on. If patients had the right technology at their bedside, providing them with better control over simple things like their environment or food orders, imagine what it would mean

for both nurses and patients? Patients would have more agency and nurses could focus on providing care and companionship – the things that have been proven to help people heal faster. Bedside patient engagement technology also aligns with the current global shift towards valuing patient outcomes and experience over simply patient flow. Rather than focus on how quickly patients can be moved through a hospital, decision-makers are looking at the patient journey through a more holistic lens and working to improve it. This is in part because it’s the right thing to do and in part because patients are demanding it. As our world becomes more digitally-enabled, patients expect hospitals to be equipped with the latest technology and they expect connectivity – even from their hospital bed. In summary, as pressures mount for hospitals to operate more efficiently, provide excellent patient experiences and deliver optimal health outcomes, we think the future lies in the hands of the patients. By unlocking new possibilities that come with patient engagement, everyone wins. We’ve already seen proof that bedside patient engagement technology can transform patient experiences and outcomes – H and we’ve only just begun. Q

FEBRUARY 2020 HOSPITAL NEWS 11

EVIDENCE MATTERS

Bringing home the evidence on

dementia villages By Carli Wallington

ately, you may have heard about dementia villages in the news. Dementia villages are long-term care homes that resemble villages and are designed for people with advanced dementia. Dementia is a condition that affects the brain and makes everyday tasks – both mental and physical – more difficult as time goes on. The most common type of dementia is Alzheimer disease. Other types include Lewy body, vascular frontotemporal, and dementia associated with other conditions like Parkinson disease. More than 400,000 Canadians live with dementia – most are over the age of 65. People with early to moderate dementia can often live in their home when supported by family, friends, or home care services. But people living with advanced dementia need more care. Over time, dementia affects the ability to carry out everyday activities, like eating, bathing, dressing, and toileting. People with dementia who can no longer live safely in their own homes are often moved to long-term care homes with around-the-clock care. As Canada’s population ages, the number of people living with dementia will increase. As a result, there will be a greater need for effective care models to support these individuals during the early, moderate, and advanced stages of dementia. The dementia village – also known as the Hogeweyk Care Concept – is an innovative care model for people with advanced dementia. The first dementia village, De Hogeweyk, was developed in the Netherlands. Before its transformation, De Hogeweyk was a traditional nursing home. The redesigned De Hogeweyk is equipped with townhouse units that are shared by small groups of residents with similar lifestyles and interests. Further, all the services of a small village are available

DEMENTIA VILLAGES ARE LONG-TERM CARE HOMES THAT RESEMBLE VILLAGES AND ARE DESIGNED FOR PEOPLE WITH ADVANCED DEMENTIA. to residents, like a village supermarket, restaurant, pub, and theatre. These design elements allow residents to live life and receive care in a more homelike setting. Person-centred care at De Hogeweyk is centre stage. This type of care focuses on meeting the needs of the individual, while honouring their values, choices, and preferences. Assisted when necessary by staff, volunteers, or family, residents participate in everyday activities that are meaningful to them, like shopping at the village supermarket, preparing meals, enjoying the garden, or attending a concert. For many, dementia villages based on the Hogeweyk Care Concept are a new and exciting way to care for people with advanced dementia. But we must ask ourselves — what does the evidence say? To answer this question, CADTH reviewed the emerging evidence on dementia villages. CADTH is an independent agency that finds, assesses, and summarizes the research

on drugs, medical devices, tests, and procedures. Below are some key findings from CADTH’s review. First, CADTH sought to answer the question: Do dementia villages improve residents’ quality of life? How individuals and researchers define “improved quality of life” can differ, but some examples for someone living with advanced dementia might include being more physically active, using less medication, or experiencing less agitation or anxiety. Currently, there’s not enough evidence to confidently say whether dementia villages improve quality of life for residents. However, dementia research has found that certain design factors may improve quality of life – such as, the design of small-scale, home-like group living environments, as well as access to outdoor space and gardens. These factors are key elements that have been incorporated into the dementia village concept.

Second, knowing whether a program produces good results for the money spent is important for those making decisions on whether to incorporate dementia villages into the current health care system. Unfortunately, not enough information on the cost-effectiveness of dementia villages was found to draw any conclusions. In-depth cost evaluations are certainly needed. What is known is that financial aspects, such as one-time costs (like the building of a facility) and on-going operational costs (like the possible need for more staff), would need to be considered. Importantly, if dementia villages were to be made widely available in Canada, we must consider how easy or hard it is for individuals to access or use these villages. High monthly costs for residents in private facilities, limited availability for publicly funded spots, and limited accessibility for those living in rural or remote communities could make it hard for many Canadians to access dementia villages. Overall, many see dementia villages as an attractive alternative to traditional long-term care homes – a place where people with severe dementia can live their lives with dignity and respect. Several dementia facilities modeled after the Hogeweyk Care Concept are planned for or under construction in Canada. As these facilities are established, it is important that good-quality evidence is collected on the benefits and costs of this type of care. CADTH’s Health Technology Expert Review Panel (a committee that offers direction on CADTH projects) also created a position statement from this bulletin. Both this and the bulletin are freely available at cadth. ca. Visit our website to learn more about CADTH, follow us on Twitter @CADTH_ACMTS, or speak to a CADTH Liaison Officer in your H region. ■

Carli Wallington is a Knowledge Mobilization Officer at CADTH. 12 HOSPITAL NEWS FEBRUARY 2020

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Supply versus demand:

Extending the reach of geriatric medicine to match the needs of our aging population By Paula Rochon and Nathan Stall his decade, Canada will be crowned as a super-aged nation – by 2026, more than 20 per cent of our population is estimated to be 65 years and older, the majority of whom will be women. As our aging population increases, so too will the demand for health services. Aging is universally relevant – if we are not already part of the 65-plus bracket, we are either caring for someone in this group or will eventually be in it ourselves. While chronic conditions including heart disease and diabetes impact some of us, aging affects all of us. For women specifically, aging holds particular relevance. They account for almost 55 per cent of the older age group and this proportion increases with advanced age. Geriatricians are central figures for our aging population, but the gap between supply and demand is widening. Canada is home to only 304 geriatricians and most are concentrated in urban areas, adding another layer of difficulty in terms of access. Our health system is largely based around intervening once there is an illness, but geriatricians play an important role in prevention and helping older people live independently in their homes. While we do need more geriatricians, we will not be able to create the army of physicians that would be required to provide one-on-one care for all older Canadians. As a result, we must implement alternative strategies and new models of care to extend the reach of these specialists. Canada is doing this through research, which has widened the capacity of geriatricians beyond one-to-one consultations. Research has and will continue to provide healthcare professionals with the evidence needed

to best care for our aging population. We have excellent geriatricians who double as clinician scientists working to create the evidence that all health care providers will need to improve the care of older adults for the future. The American Geriatrics Society has proposed a four-pronged approach to increase the reach of geriatricians that can also be applied here in Canada: more geriatric experts, more geriatric training for the whole work force, more public health education to empower older adults and caregivers, and more health policy that can support us all as we age. To encourage more geriatric experts in Canada, we need to implement earlier exposure to this field in med-

ical school so that future doctors are made aware of the specialty early on in their careers. More geriatric training for the entire workforce will also help increase the reach of geriatric medicine and relieve some of the demands on our stressed health system. This is being done in family medicine with the ‘Care of the Elderly’ training, which offers additional expertise for primary care providers in how to care for older adults. We need to continue to implement shared models of care where geriatricians work with teams of primary care providers to help build their capacity in geriatric medicine. Everyone on the health care team – from the

receptionist who first interacts with the patients, to the nurses, pharmacists, social workers and physicians – all need expertise in caring for older people. Improving care is not an individual responsibility, it takes a village. We also need more public health education to empower older adults and their caregivers. Family caregivers play an important role in helping our older demographic age in place, but they need the proper support, clinical education and resources. Caregiving – which traditionally falls to women – can be stressful and impact the health of caregivers themselves. Caregivers are recognized as central to the circle of care and posiContinued on page 15

Paula Rochon is a geriatrician, the vice-president of research at Women’s College Hospital and the Retired Teachers of Ontario Chair in Geriatric Medicine at the University of Toronto and Nathan Stall is a geriatrician and research fellow at the University of Toronto and Women’s College Research Institute. 14 HOSPITAL NEWS FEBRUARY 2020

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NEWS

At-risk seniors benefit from expanded geriatric assessment program By Maryanne Matthews enior patients at Thunder Bay Regional Health Sciences Centre are receiving the right care, at the right time, and by the right provider thanks to expanded coverage for the Geriatric Assessment program. Beginning in the Emergency Department, the program streamlines the assessment process of at-risk seniors (aged 65 years and older) through consultation with internal geriatricians and the Hospital Elder Life Program (HELP). Collaboration with external partners such as St. Joseph’s Care Group (SJCG), Alzheimer’s Society, Superior North Emergency Medical Service, and the North West Local Health Integration Network’s (LHIN) Home and Community Care, is also crucial to the program’s success.

“Senior patients often require more specialized attention within our health care system. In addition to requiring health care more often, their needs are different from the general population,” says Susan Veltri, Geriatric Care Coordinator. “The Geriatric Assessment program is a great fit for their needs. After a successful trial of the program, we saw a need to not only make it a permanent service, but to expand coverage to seven days a week so that even more patients can be screened and assessed.” The assessment process looks for signs of geriatric syndromes, including mobility issues, weakness, frailty, functional decline, pain, cognitive impairment, dementia, delirium, and other risk factors often associated with

seniors. “Early assessment allow for early interventions, which is especially crucial for at-risk seniors,” says Veltri. The program also supports discharges for patients who do not require acute care in a hospital setting and works with community partners to provide a smooth transition to home or other programs and services that would best address their needs, such as SJCG’s geriatric programs. By identifying their needs sooner, the average length of stay for senior’s of the program has decreased by half – meaning that vulnerable senior patients are not spending more time in the hospital than needed. Additionally, over 150 unnecessary hospital admissions have been avoided this year.

“By providing senior-friendly care early, we reduce the number of unnecessary admissions or days spent in the hospital and achieve improved continuity of care, enhanced patient experiences and better outcomes,” says Veltri. “Most importantly, our senior patients and their families and caregivers have been very happy with the care received and the ongoing support provided after discharge.” To learn more about our Hospital’s commitment to seniors’ health, visit H www.tbrhsc.net. ■

Maryanne Matthews is a Communications Officer at Thunder Bay Regional Health Sciences Centre

Supply versus demand Continued from page 14

MORE GERIATRIC TRAINING FOR THE ENTIRE WORKFORCE WILL ALSO HELP INCREASE THE REACH OF GERIATRIC MEDICINE AND RELIEVE SOME OF THE DEMANDS ON OUR STRESSED HEALTH SYSTEM. tively impact the health outcomes of the older adults they care for. By providing at-home care, these caregivers are essential in allowing older people to age inplace, reducing the need for admission to long-term care facilities. Our aging population relies heavily on family caregivers, so we need to ensure that they are given the proper support and resources to do this important role. Finally, to lessen the demands on our health system, we need to work with our communities and government to implement stronger health policies around social isolation and loneliness. Loneliness is common among older adults – particularly women. Healthcare providers may consider social prescribing to connect www.hospitalnews.com

lonely older adults with sources of support in the community. Helping older adults stay engaged and connected can keep them healthier longer, which will optimize healthcare utilization. Community design can also reduce loneliness. By making neighbourhoods more walkable and accessible, we can promote health and wellness among our aging population. Paired with care from our geriatricians, health policy that supports us as we age can expand support for our aging population and improve health and wellness with aging. Individually, aging impacts each of us. As a collective, we need to work to extend the reach of geriatric medicine – H the health of our nation depends on it. ■

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WOUND CARE

Prioritize wound care to reduce hospitalizations and health-care costs IMPLEMENTING THESE KEY ACTIONS WOULD IMPROVE PATIENT OUTCOMES AND REDUCE SPENDING ON WOUNDS • On a daily basis, people are admitted to hospitals for infected wounds and are dying from pressure-related injuries (bed sores). Every four hours an amputation due to diabetic foot ulcers takes place, and new research shows this number is on the rise. • In Ontario evidence-based wound care is not integrated and equitably accessible to patients. For example, interprofessional teams often do not have access to basic wound care products such as advanced dressings. Health-care professionals do not have access to standard of care technology and practices that could detect and prevent pressure injuries from developing. • With investment in better wound prevention and management earlier on in the patient journey, the Government of Ontario could improve patient outcomes, reduce hospitalizations and readmissions, and quickly cut health-care costs related to wounds. • For example, adoption of best practices could reduce wound costs in home care by 40-50 per cent – approximately 50 per cent of home care visits involve wound care.

• Despite the fact that at least 70 per cent of all pressure injuries are preventable, 25 per cent of people in any care setting in Ontario have a pressure injury on any given day. Pressure injuries can extend a hospital stay by four to 11 days.

WOUND CARE HAS NOT BEEN PRIORITIZED IN ONTARIO OR ACROSS CANADA • The Government of Ontario has taken initial steps: draft wound care pathways are currently being developed, and funding for offloading devices has been provided to help pre-

A PERSON’S HOSPITALIZATION AND HOME CARE NEEDS INCREASE WITH COMPLEX OR SEVERE WOUNDS • A person with a diabetic foot ulcer that heals as expected spends an average of five days in the hospital, emergency rooms and clinics, whereas a diabetic foot ulcer that results in an amputation increases this time to an average of 70 days. • A surgical wound that becomes infected increases a person’s hospitalization by 11 days in Canada. 16 HOSPITAL NEWS FEBRUARY 2020

A SURGICAL WOUND THAT BECOMES INFECTED INCREASES A PERSON’S HOSPITALIZATION BY 11 DAYS IN CANADA. vent amputations due to diabetic foot ulcers. However, more must be done. • Wound care pathways, education and other supports are standard in many nations such as the United Kingdom, Spain, Netherlands and Sweden. Yet Canada has fallen far behind its peers by not keeping up with advances in standard of care technology and implementing best practices.

• Ontario needs better wound care policies to support best practice and pathways to ensure appropriate outcomes, access to wound care experts and basic education for patients and health care professionals (from nurses and family physicians to surgeons and chiropodists) and access to evidence-based H technology and products. ■

Wound care costs Ontario at least $1.5 billion annually in direct cost Wounds Canada urges the Government of Ontario to prioritize wound care, ensuring that patient care is equitable, timely, non-fragmented and accessible across the province. To improve patient care, reduce hospitalizations and lower spending on wounds, key actions must include: • Developing policies that prevent wounds such as pressure injuries (bed sores) and infected wounds in acute and home care settings • Increasing wound-related education for health-care providers, patients and families • Ensuring Ontario’s interprofessional teams include wound experts • Implementing wound care pathways from hospitals to home and community care with set measurables, monitoring and evaluation • Providing access to products and technology that are evidence-based and improve patient outcomes

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WOUND CARE

The pressing need for new strategies to target Canada’s

chronic wound epidemic By Rosemary Hill he critical link between long-term chronic wounds, poor quality of life and increased risk of mortality, is an issue drawing urgent attention amongst health professionals. There are an estimated 11 million people living with diabetes or prediabetes in Canada, and of these between 15-25 per cent of people will go onto develop a diabetic foot ulcer (DFU) during their lifetime. In addition, lower leg ulcers are estimated to affect between 50,000-500,000 Canadians, with venous leg ulcers (VLUs) accounting for 90 per cent of all lower extremity ulcers. These are serious statistics given that 85 per cent of lower limb amputations are preceded by the development of a neuropathic foot ulcer. For diabetic patients with ulcers, the risk of death is increased 2.5fold compared with diabetic patients without foot wounds. Yet for an issue this serious, new strategies are clearly needed. Understanding the aetiology of the ulcer and its link with a patient’s lifestyle is insightful and assists in defining the general management approach, however, the potential role of new technological interventions must not be underestimated. Indeed, there is much innovation taking place, the adoption of which in normal clinical practice could have far reaching effects.

GROWING BODY OF EVIDENCE A growing body of evidence is emerging to recommend the use of negative pressure wound therapy (NPWT) in the management of patients with delayed healing or stalled lower extremity wounds. Whilst earlier versions of this canister-based technology have been highly effective clinically vs standard care, they retain limitations in their practical mobility, use in a community setting, and overall clinical management.

The technology, however, has been evolving from canister-based platforms of the treatment, to smaller, highly portable, single-use versions; and research is showing a remarkable improvement over an already proven and effective methodology. A recent multi-centre randomized controlled trial (RCT) carried out by Dr. Robert Kirsner et al., across 18 Canadian and US hospitals looked at wound healing when comparing the use of single-use negative pressure wound therapy system (sNPWT) with traditional NPWT (tNPWT) in the management of patients with lower extremity ulcers over 12 weeks. The results were promising, showing a significant reduction in wound area (by 39.1%), depth (by 32.5%) and a reduction of 91.1 per cent in overall wound volume when sNPWT was used compared to traditional NPWT. As well as improved clinical outcomes the study also noted a reduction

in the number of dressing changes as sNPWT can be worn on average 3.4 days longer. Not only does this have clear benefits in terms of reducing nursing time, patients are required to attend less dressing change appointments which can become a barrier to living a ‘normal’ life.

THE ECONOMIC BURDEN Healing time, frequency of dressing change and incidence of complications are well established factors driving the cost of wound care. Both VLUs and DFUs impose a substantial cost burden on the Canadian health system, both estimated at $100 million and $547 million respectively. Existing methodologies of intervention need updating. The appropriate use of innovative and clinically proven wound management technologies can and must play their part in a step-change strategy.

This may require an evolution in the goal setting, clinical practice, and procurement process, but the upside of a coordinated effort is a direct impact on a significant area of medicine that will improve quality of life and reduce mortality.

INNOVATION SHOULD BE AT THE FOREFRONT The recent evidence from Dr. Kirsner’s study highlights how the adoption of technology and new treatment pathways can help to alleviate some of the current pressures. With an ageing population and the projected rise in diabetes, it is vital more than ever, that a strategy is in place to address the burden of wound care and ways to improve patients’ quality of lives. This includes embracing innovations which disrupt the inefficiencies that we are currently facing with wound care practice. For more information on the Kirsner study: https://onlinelibrary.wiley. H com/doi/full/10.1111/wrr.12727 ■

Rosemary Hill BSN CWOCN WOCC(C) is a Nurse specialized in Wound Ostomy Continence at Vancouver Coastal Health – Lions Gate Hospital. www.hospitalnews.com

FEBRUARY 2020 HOSPITAL NEWS 17

NSWOCs Enza Browne and Kelsey McIntyre review wound care products with surgeon, Dr. Niv Sne.

Treating wounds in high-risk areas By Elise Copps obody likes to talk about poop. We leave that business in the bathroom. In the world of wound management, however, this taboo topic can’t be ignored. Wounds frequently exposed

to fecal matter can be incredibly hard to manage. That’s why the Skin, Wound, and Ostomy team at Hamilton Health Sciences’ Hamilton General Hospital has taken a different approach to treating wounds in high risk areas. “Large wounds in the rectal area can require frequent dressing changes,”

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says Enza Browne, a nurse specialized in wound, ostomy and continence (NSWOC). “This limits the type of dressings we can use. Because of their location, it is also very difficult to completely prevent feces from getting in the wound area.” Enza and her colleagues noted that patients arriving at the hospital with necrotizing fasciitis or large pressure sores around their buttocks were treated for several months or years before the wound came under control. Some never healed. Many of these patients had limited or no lower body movement, and developed significant wounds at home from sitting or lying for extended periods. The team researched options for improving their wound management, and proposed an alternative treatment to their surgical colleagues – a diverting ostomy. In a diverting ostomy, a small opening, called a stoma, is created in the abdomen, and the bowel is diverted to that opening from the anus. Waste moves through the stoma and collects in a discreet pouch that is emptied several times a day. Initially, this seemed like a radical way to address wounds, but the value of this option soon became clear. “We worked with colleagues in general surgery and plastic surgery to make recommendations for the benefits of diverting ostomy,” says Kelsey McIntyre, who works alongside Enza as an NSWOC. “These wounds are at serious risk of infec-

tion, and this is a proven way to help them heal effectively.” The wound team works collaboratively with both general and plastic surgery to debride the wound area and prepare the patient for the ostomy procedure. With an ostomy, the wound can be dressed with more effective products. The team often uses instillation negative pressure wound therapy for these cases, which applies both negative pressure and a topical wound treatment solution to speed healing. Healing time for these wounds has been significantly reduced in many cases. When the option is proposed to patients, some are hesitant at first, but once the benefits are explained they come around to the idea. Many patients opt to keep their ostomies, even though the procedure can be reversed. People who have had one major wound are at greater risk for another, which contributes to that decision. “I think they adapt to the ostomy. It can improve their quality of life,” says Kelsey. “Especially for people with paraplegia who are prone to pressure injuries. This makes sense as a long term solution.” The practice is also favoured by NSWOCs at other Hamilton Health Sciences sites for patients with similar issues. Patients who are discharged from the hospital with a new ostomy are referred to a community NSWOC who provides continued education and support so they H can resume daily activities. ■

Elise Copps works in communications at Hamilton Health Sciences Centre. www.hospitalnews.com

WOUND CARE

Trends in lower-extremity amputations for diabetes and peripheral artery disease By Jennifer Stranges ogether, diabetes and peripheral artery disease account for more than 80 per cent of lower-extremity amputations in Canada. A recent study by St. Michael’s Hospital vascular surgeons, Dr. Mohammed Al-Omran and Dr. Charles de Mestral, has found that lower-extremity amputations related to diabetes and peripheral arterial disease have increased over the last decade in Ontario. Dr. de Mestral shared ways patients with diabetes or peripheral artery disease can be more vigilant about their lower extremity care, which he says starts with daily foot checks. What motivated you to explore trends in the rate of lower-extremity amputations related to diabetes and peripheral artery disease? As vascular surgeons, we treat people

Dr. Charles de Mestral. with diabetes and peripheral arterial disease at risk of amputation on a weekly basis. Those who come to St. Michael’s Hospital benefit from multidisciplinary limb salvage efforts. However, we know there are serious gaps in foot care across many parts of Ontario and Canada. What are some of the clinical, psychological, social and economic burdens related to lower-extremity amputations?

In people with diabetes or peripheral artery disease, leg amputation is one of the most feared complications. Leg amputation often severely limits a person’s mobility and independence. It takes a major toll on the patient, their family and their caregivers, in terms of mental health as well as financially. There is usually a lasting impact on quality of life. What was most surprising about your findings? Unlike the decreasing incidence of heart disease and stroke, we found that amputations have recently increased. Part of this rise is likely related to the rise in diabetes. Diabetes currently affects 10 per cent of Ontarians and is expected to increase by 20 per cent over the next decade. A rise in amputations related to diabetes was also recently reported in the United States. These data should serve as a call to action. We need to do more when it

comes to foot care for people with diabetes and peripheral artery disease. What’s next for this research and for lower-extremity amputation prevention? We are looking at regional differences in amputation rates and prevention efforts across Ontario. We need to improve screening for foot problems in people with diabetes and peripheral artery disease. We also need to better coordinate the multidisciplinary care they need to prevent amputation when a foot problem arises. In the context of amputation prevention, what advice would you share with a patient who has diabetes, peripheral artery disease or both? Check your feet daily for wounds, and if you notice a new foot or toe issue – such as pain, redness, black discolouration, wounds – then see your doctor or foot specialist as soon H as possible. ■

Jennifer Stranges is a communications advisor at Unity Health Toronto.

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Community Health Navigators offer ‘safety net’ for patients going home By Emily Dawson etting ready to return home after an extended hospital stay has the potential to reveal a host of emotions for both the patient and their family and friends. While there is often joy in the prospect of going home, many people feel anxious about managing their new reality. Enhancing how we prepare people for the transition home is one of Unity

Health Toronto’s quality improvement goals. Our care doesn’t stop once a patient is discharged, though. We know that many people encounter issues once home that can result in declining health or emergency department visits. At Providence Healthcare, we introduced the Community Health Navigator role to support patients after discharge and rehab patients now receive either a live or an automated phone

Photo credit: Emily Dawson

Kelly Tough (L) and community health navigator Monica McCullagh say people appreciate that care doesn’t stop once they return home. call – based on their preference – to check on how they’re doing. These calls happen at the 48-hour, 30-day and four-month points after discharge. “The basic things we cover are making sure the discharge plans are

Geriatric Psychiatric Clinic supports complex needs of older adults he Geriatric Psychiatry Clinic is part of a multidisciplinary program, The Regional Geriatric Program of Toronto, housed at Providence Healthcare since 1988. The role of the clinic’s geriatric psychiatrists is to assess, consult, and treat elderly patients who may have a mental health issue, dementia syndrome, behaviour disorder, or a psychosocial problem. Symptoms that are of concern and may require long-term treatment include paranoia, disturbances of mood, hallucinations, misidentification phenomena, and disturbances of behaviour. These symptoms contribute to significant impairment and compromise interpersonal relationships, and education about these symptoms is part of the treatment offered by the geriatric psychiatrists. The more families and caregivers understand about symptoms associated with an evolving dementia, the more we can minimize the use of psychoactive medications.

Photo credit: Ramon Syyap

By Selma Al-Samarrai

Dr. Ian Ferguson is a geriatric psychiatrist in the clinic. Referrals to the clinic come primarily from family physicians, geriatricians, and neurologists. A critical component of the program is the community outreach service, which involves health care professionals visiting patients in their homes to identify factors that contribute to frailty in the elderly. Most of the patients coming to the clinic are seen in the community by

Selma Al-Samarrai is a communications advisor at Unity Health Toronto. 20 HOSPITAL NEWS FEBRUARY 2020

one of the occupational therapists prior to their first appointment. The occupational therapist does a cognitive screen and preliminary appraisal of the social circumstances in which the patient lives. The geriatric psychiatrist is able to then use this information when offering treatment options. The recommended treatments vary depending on the patient’s diagnosis, symptoms, and circumstances. A referral to Providence’s social worker is invaluable. The social worker visits the patient at home to discuss problems they are encountering, and may make recommendations including programs that are available for the patient and their family in the community. One of the geriatric psychiatrists sees housebound patients in their homes and the other geriatric psychiatrist does consultations within the rehab programs at Providence. As more patients are choosing to remain at home for the duration of a dementing illness, there is an increasing need for community involvement H like the one done by this program. ■

being followed, that physician referrals are in motion and that they have the medications they need,” says Monica McCullagh, one of three Community Health Navigators (CHN). Even the automated calls, which can happen in five different languages, have a high-touch component. On some questions, such as those that assess caregiver strain, a concerning answer will trigger a live call from the CHNs. “We get great insights through these conversations that lead to important feedback for our programs. The common things we hear are around the logistics of their discharge, concerns about managing at home, and questions about home and community services,” says McCullagh. For patients or caregivers who are struggling, the CHNs will talk to them about community resources and encourage them to seek help from appropriate professionals. “We may not always have the answers but we know how to connect you,” explains Kelly Tough, manager of patient flow. “There’s a sense of comfort that we’re still caring for you.” The data provides evidence that these calls are making a difference and mitigating some of the challenges of returning home. “We’re a safety net; we’ve even been called angels. People appreciate knowing they’re not alone,” says McH Cullagh. ■ Emily Dawson is a senior communications advisor at Unity Health Toronto. www.hospitalnews.com

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ETHICS

Organs as trade commodities By George Stremplis he organ transplantation process has increasingly become an important issue that needs to be tackled by not only healthcare providers, but society in general. Organ failure has spiked over the years, creating the need for a constant source of new viable organs. According to the Organ Project, there are 4,500 people waiting for an organ donation in Canada with the number of organ failure-related deaths to reach 260 people every year due to the fact that they did not receive the necessary viable organ. Although the number of donors in Canada is considerably lower than other countries (e.g. Spain, the United Kingdom, the United States), it is not the only country that suffers from an inadequate supply of organs available for life-saving medical interventions. This lack of available organs has prompted a salient and ongoing conversation between the medical community, patients, bioethicists, lawmakers, and the general public. While many solutions have been proposed, few have sparked such a heated debate as making organs available for sale. The severity of the organ transplantation shortage has prompted some healthcare analysts and providers, as well as bioethicists, to declare the need to change the established rules and move towards a market of human organs. In 1998 the International Forum for Transplant Ethics concluded

that trade in organs should be regulated rather than banned. Bioethicists Charles A. Erin and John Harris proposed a single purchaser system like the National Health Service (NHS) or Medicare that would undertake the responsibility of creating a fair system of medical priority for the recipients of purchased organs. Erin and Harris noted that this system should be limited to fixed geographical areas (e.g. the European Union) in order to avoid the exploitation of low-income countries, while simultaneously creating a condition in which organ vendors would know that their organs would have a higher chance of being donated to family or friends. Under this system, the organ vendors would be compensated for donating, but they would be forbidden from managing the sale of their organs themselves. Julian Savulescu, a prominent bioethicist, expanded on the above argument by suggesting that people have an intrinsic right to sell their body parts. Additionally, he recommends that as long as the personal risk involved in the organ donation process does not outweigh the benefits for the person and/or society in general, then there is no reason to ban an organ market. Furthermore, Savulescu notes that people should be able to make free and informed decisions about their bodies even if such decisions are motivated by a state of poverty. In fact, Savulescu says that it is an injustice to not provide impov-

THE SEVERITY OF THE ORGAN TRANSPLANTATION SHORTAGE HAS PROMPTED SOME HEALTHCARE ANALYSTS AND PROVIDERS, AS WELL AS BIOETHICISTS, TO DECLARE THE NEED TO CHANGE THE ESTABLISHED RULES AND MOVE TOWARDS A MARKET OF HUMAN ORGANS. erished persons with an opportunity to change or escape their position in society by selling their organs. However, is it safe to assert that the legalization of an organ market may help to improve social poverty and at the same time resolve the lack of available organs for transplantation? Can persons in extreme conditions of poverty make the autonomous and free choices that are required when it comes to the commodification of their body parts? Moral philosophers over the years, like Aristotle and Immanuel Kant, have argued that our choices are not truly free and autonomous when we are in an impoverished state insofar as our free will can be affected by our circumstances. Based on this perspective, it is typically thought that trading one’s organs for money as a means to escape an impoverished state cannot justifiably be considered an entirely free choice. At the same time, Erin and Harris’s suggestion to confine organ trading systems to fixed geographical areas is unlikely to eliminate the issue of exploiting

low-income populations since higher earning classes will have little-to-no incentive to sell their organs. Consequently, a market of underprivileged people that harvest their body parts in order to escape their circumstances is likely to occur. At this point we may be bound to ask: how do we solve the issue of needing organs if we do not make organ transplantation a trade commodity? The answer may be found in some combination of short-term and longterm proposals. It will likely be important to use and combine modern and emerging biotechnologies (such as stem cells, implantable devices, organogenesis) in order to shape a new way of replacing organs in the future. At the same time, we have to raise awareness of the need for available organs and clarify the processes required for transplantation. More than that, it would be helpful to advocate for better available nutrition and healthcare in order to prevent some of the diseases that cause organ failure in the H first place. ■

George Stremplis holds a Master’s degree in Moral Philosophy and Bioethics from Aristotle University of Thessaloniki, Greece. 22 HOSPITAL NEWS FEBRUARY 2020

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Expert Expertise CSC 2020’s inspiring keynotes are just the warmup. Be prepared to immerse yourself in the practical, immediately applicable advice and implementation strategies shared by the phenomenal lineup of field experts featured in this year’s educational program, which is sponsored by two highly respected institutions: Ryerson University and the University of Victoria Gustavson School of Business. The schedule of more than 22 sessions will cover every important phase of leadership imaginable within the conference’s three main educational tracks: • Infection Prevention & Cleaning • Sustainability & Social Responsibility

• Leadership & Next Gen Strategies. Below is just a sampling of the timely topics and expert presenters you will discover at CSC 2020. • Sunnybrook Health Sciences environmental support services director, Lou Fernandes, will present Implementing New Products and Technologies into Your Organization. • M.Sc. applied scientist and Wilcox EVS Green Cleaning & Infection Control Specialists founder/owner, Heidi Wilcox, will present two notto-be-missed sessions: New Technologies & Innovations for Infection Prevention & Control and Sustainability Benchmarks for Cleaning Results. • Successful Change Management Tips for Environmental Service and Cleaning Leaders will be led by nurse and Clorox Canada infection control specialist, Barley Chironda. • Reducing Overall Cleaning Costs

CSC 2020 is ripe with other opportunities for professional development, not the least of which is the expo portion of the conference, which will feature such powerhouses in infection prevention, cleaning and sustainability as 3M, Cascades, Buckeye, Nilfisk, Kaivac, Unger, Perfect Clean, Daniels Health – to name but a few – all in one convenient location. These knowledgeable manufacturers and service providers will show you how the latest innovations can help you do more with less – less budget, less manpower and less waste – while helping you run your departments effectively and efficiently in order to have the highest level of clean. Additional formal and informal networking opportunities include the evening Networking Reception, informal continental breakfasts, lunches, and the impromptu meetings that naturally occur at a conference of this caliber. If you haven’t registered yet, check out the Top 10 reasons you must attend CSC 2020, on the “Why Attend” page at https://sustainabilityconference.ca. If you need help convincing a boss that you need to attend CSC 2020, click the button on the bottom right of the Why Attend page and fill in the few blanks on the prewritten letter. We guarantee it will be hard for anyone interested in promoting the professionalism of your team and facility to deny your request! See you in Toronto! For more information and to register, visit https://sustainabilityconference.ca/ Q H

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FEBRUARY 2020 HOSPITAL NEWS 23

FROM THE CEO’S DESK

Innovative care for veterans w By Dr. Jocelyn Charles ementia is the most common reason for placement in long term care in Ontario, particularly when associated with behavioural symptoms. Long-term care residents with dementia commonly exhibit behaviours that disrupt the lives of other residents and increase the complexity of their care. Behavioural and psychological symptoms of dementia (BPSD), defined as signs and symptoms of disturbed perception, thought content, mood, or behaviour, include: agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, wandering, and a variety of socially inappropriate behaviors. One or more symptoms of BPSD will affect nearly all people with dementia during their illness, with the most common symptoms being depression, apathy, and anxiety. In a review of BPSD-focused

studies, the prevalence of one or more BPSD symptom, in long term care residents was 78 per cent. Canada’s war veterans are predominantly male, with military service-related physical and psychological injuries, and have a higher prevalence of physically aggressive behaviours. At the Sunnybrook Health Sciences Centre Veterans Centre, 53 per cent of veterans have a diagnosis of dementia. With the increasing number of long term care residents with BPSD, and in recognition of the increasing importance of the environment as cognition declines, many long-term care homes have designed supportive and therapeutic environments. In 1996, a study of 186 Sunnybrook veterans with dementia using the Cohen-Mansfield Agitation Inventory, found that 43 veterans (23%) had significant behavioural symptoms. Of these, 33

LONG-TERM CARE RESIDENTS WITH DEMENTIA COMMONLY EXHIBIT BEHAVIOURS THAT DISRUPT THE LIVES OF OTHER RESIDENTS AND INCREASE THE COMPLEXITY OF THEIR CARE. (76%) were physically aggressive a few times a day to several times an hour. For the same group of veterans, using the Overt Aggression Scale, over a one week period, 10 veterans received mild to moderate injuries as a result of aggressive incidents. With the growing number of veterans with dementia and associated BPSD, the Sunnybrook Veterans Centre opened the Dorothy Macham Home (DMH) in Toronto, Canada, in May of 2001. DMH is an innovative care facility specifically designed for veterans with BPSD.

The DMH model of care represents a radical shift from the traditional “behaviour assessment unit” model to a more progressive, individualized “living” model, and was modeled on the ADARDS Nursing Home in Tasmania. The primary focus of the home is to provide veterans with a therapeutic place to live out the stage of their dementing illness when disruptive behaviours are prevalent. To enhance quality of life, this environment needs to be non-stressful, constant, familiar, and safe.

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FROM THE CEO’S DESK

s with dementia Designed with local and international clinician and architect input, DMH looks like a one-story house, with 10 private rooms, an accessible home-like kitchen and dining room, and an enclosed, secure garden. An indoor wandering path allows residents to move around common areas; the provision this type of path has been associated with lower levels of agitation among people with dementia. All locked doors are disguised, and an unlocked door is close by to minimize frustration associated with a sense of confinement. Home-like features, including a fireplace, fish tank, large garden windows, and concealed clinical equipment, are balanced with safety features, including two means of exiting each room, floor sensors in bedrooms to detect entrance by another resident, and safe applianc-

es in the kitchen. In recognition that some veterans were prisoners of war, the garden fence was concealed with shrubs to avoid this visual reminder. The all-professional nursing staff was selected through a behaviour-based interview process and specifically trained to provide flexible, needsbased care, with a ratio of 1:3.3 from 700-2300h and 1:5 from 2300-700h. The care team also includes recreation, creative arts and music therapists, spiritual care, a family physician, and a geriatric psychiatrist. A broader interprofessional consulting team is involved as necessary. Programming is flexible and tailored to the needs and preferences of the individual veterans. Following the opening of the DMH in 2001, there was a significant decrease in behaviour-related incidents

on the six Dementia Support units. This could be attributed to the removal of the most aggressive residents from the Dementia Support units to DMH. In addition the frequency of resident behaviour-related employee incident reports dropped by 70 per cent in the dementia support units. This drop was maintained at 28 incidents (for staff caring for 190 residents) in 2008 and increased to 60 incidents in 2017 (for staff caring for 232 residents). The DMH staff reported 21 and 10 resident behaviour-related employee incidents in 2008 and 2017 respectively. Only no or minor harm resulted from all employee incidents. The DMH model as a whole, including therapeutic design, staff characteristics and approach, and staffing ratio, reduced behaviour-related incidents and injuries to both residents and staff

By Dr. Jocelyn Charles on the Dementia Support units over a 16-year period. Ensuring adequate access to these specialized beds is a key success factor for maintaining reduced incident rates and needs-based care for people with behavioural and psychoH logical symptoms of dementia. ■

Dr. Jocelyn Charles is the Medical Director, Veterans Centre, Sunnybrook Health Sciences Centre.

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FEBRUARY 2020 HOSPITAL NEWS 25

LONG-TERM CARE NEWS

Using Artificial intelligence to detect and prevent falls By Rebecca Ihilchik t’s every family member’s nightmare: a call from the long-term care home that Mom or Dad has had a fall. Are they hurt? Do they need to be taken to the emergency room? And how can staff make sure this doesn’t happen again in the future? Falls prevention is an important element in maintaining the health and well-being of older adults in long-term care. Not only is prevention vital to keep residents – especially those living with dementia – safe, falls are costly to the Ontario healthcare system. Memory care falls cost Ontario an estimated annual amount of $760 million. SafelyYou is a technology that uses wall-mounted cameras enabled with artificial intelligence (AI) to evaluate resident falls in long-term care. A spinoff from UC Berkeley’s Artificial Intelligence Research Lab – one of the top five AI research groups in the world – SafelyYou reduces falls and resulting visits to the emergency room, and helps staff provide immediate and appropriate care to residents. Studies have shown that, on average, using SafelyYou decreases falls by 40 per cent and emergency room visits by 70 per cent. The SafelyYou system is especially valuable for residents living with dementia, who often fall unwitnessed and are unable to express to staff how they ended up on the ground. From the more than 2,500 video recordings SafelyYou has analyzed to date, the company has found that a third of the time the resident didn’t fall at all but moved themselves to the ground intentionally. “What we do is provide a voice for those who can’t advocate for themselves at a critical time,” says George Netscher, CEO of SafelyYou. “Without the SafelyYou video, staff have to assume the worst and treat every unwitnessed fall as a possible head injury at high cost to the health system and

SafelyYou helps staff provide residents in long-term care facilities with immediate and appropriate care. often with dramatic setbacks to the resident’s condition.”

IMPACT ON ONTARIO’S LONG-TERM CARE SYSTEM In Ontario, falls by individuals living with dementia are a significant cause of hallway healthcare, and this group is one of the hardest to support in an emergency room. A recent study by SafelyYou at Carlton Senior Living in California showed that the technology reduced emergency medical service calls by 61 per cent and decreased falls among participating residents with dementia by 31 per cent. Extrapolating these results across Ontario, SafelyYou could save the province approximately $671 million annually by reducing falls for residents

living with dementia – savings that could be redirected to increase capacity in emergency departments to reduce the effects of hallway healthcare on patients. With support from the Centre for Aging + Brain Health Innovation (CABHI), this innovative technology is now being tested in Ontario. Through its Industry Innovation Partnership Program, CABHI is facilitating the first-ever Canadian validation study of the SafelyYou technology with Toronto-based long-term care home Baycrest. “We would certainly not be in the Canadian market without CABHI’s help,” says Netscher. “Having CABHI staff not only make introductions but also sit in on calls and guide potential customers is extremely powerful and

is something no other organization I know of does.” As SafelyYou expands and attracts new customers within Ontario, it’s likely the company will hire a team and incorporate here, bringing direct foreign investment to the province. With the potential cost-savings to the healthcare system, SafelyYou represents an incredible opportunity to help reduce hallways healthcare in Ontario. Most importantly, with CABHI’s support, SafelyYou is on its way to improving the lives and health outcomes of Ontario seniors, ensuring that their families have peace of mind that their loved ones are safe and cared for. CABHI-supported projects are making a difference in the lives of older adults living with dementia and their H caregivers. Learn more at cabhi.com. ■

Rebecca Ihilchik is a Senior Communications Specialist at CABHI. 26 HOSPITAL NEWS FEBRUARY 2020

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LONG-TERM CARE NEWS

Mobilizing independence By Monica Fleck alling is a concern for anyone – especially the elderly. The risk is even greater for people who have some form of dementia, particularly if they are assigned the additional task of learning how to use an assistive walking device. As Canada’s aging population increases, so too does the number of dementia diagnoses, and the meeting of these two trends creates a very real need to help people retain or regain their mobility. Dr. Susan Hunter of the School of Physical Therapy at Western University has been studying the effects of the use of mobility aids in people with dementia. Her findings have shown that the increased mental demand of using a device makes walking more difficult, and by extension, unsafe. While recognizing that assistive devices improve

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quality of life by supporting people’s independence, the study set out to discover a way to reduce the falls risk and enhance safety. “People with dementia have a slower gait speed and an increased cognitive load – or something else demanding their attention – when using an assistive walking device,” says Dr. Hunter. Learning any new activity, such as how to use a walking aid, requires people to think and process new information more deliberately. People with dementia, who gradually lose their knowledge of how to do things instinctively, are to an extent further compromised by the need to focus more consciously on the walking task. That thought process not only includes the fundamentals of placing their feet, assessing their surroundings and consid-

Dr. Susan Hunter is developing a new assessment scale that will help reduce the risk of falls and enable people with dementia use assistive walking devices more safely. ering their destination, it also includes manoeuvering an assistive device, propelling themselves in union with the device and learning to rely on it. “The current fall-prevention guidelines and practices that work well in

the cognitively healthy older adult have not been as successful in preventing falls in people with dementia,” says Dr. Hunter. Continued on page 28

FEBRUARY 2020 HOSPITAL NEWS 27

NEWS

Gold Standard Certification Training Program for procurement professionals n today’s health care environment, increased demands and constantly shifting priorities and initiatives have those who work in this field striving to remain top of their game. Health care procurement and administration professionals must be skilled in many areas – from managing detailed and complex projects to maintaining strong communication skills and balancing well written briefing notes and tight presentations. Factor in the lack of training resources for non-clinical hospital staff, and you’re left with a definite need for a program that fills the gap in helping hospitals develop and retain back office personnel. In an effort to address this need, Mohawk Medbuy, Canada’s leading national health care shared services organization, is enhancing the skills of people in hospital procurement and other back office functions with the Gold Standard Certification Training Program. The current iteration of the 10-course initiative was co-developed in collaboration with Shared Services West.

Mobilizing independence

Continued from page 27 She believes that the answer to this problem lies in developing a new assessment scale that will help reduce the risk of falls and enable people with dementia to safely regain their mobility. The scale will establish a baseline level of physical function and outline a set of nine tasks to determine safety and ability with the mobility aid. Some of these tasks include having the person stand up from a chair and walk, manoeuver around obstacles, and open and close doors behind them, all while using their aid. In addition to data collected from participant evaluations, the scale was developed using feedback from focus groups comprised of health care professionals, including nurses, geriatri-

Wendy Murdock, Director of Member Engagement and Organizational Development at Mohawk Medbuy, leads a discussion with health care procurement professionals at a Gold Standard training session in Thunder Bay, Ontario. “Our Strategic Plan speaks to the importance of enabling, empowering, and developing the talent and expertise of our people,” says Wendy Murdock, Director of Member Engagement and Organizational Development. “We’re committed to the success of our staff, and by extension, the success of our Members. We’re thrilled to offer an opportunity for professional growth, and due to the resounding

cians, physiotherapists, occupational therapists and kinesiologists. “The expectations and message of all members of the care team need to be united. The scale outlines in a sequential order the actions that make use of the aid safe,” she adds. “It sets out consistent practice standards and allows opportunities to initiate rehabilitation and care practices that are not usually addressed in a systematic way. Gathering input from several areas of health care helps make it a more standardized tool for all care professionals to enhance safety and achieve a successful outcome,” says Dr. Hunter. The study looked at participants with dementia who are at various stages of walking aid experience, and evaluated variables such as their speed, pace, and stride length. Results showed that the mental demands of using these devices negatively impact balance, gait and steadiness – all

Monica Fleck works in communications at McCormick Care Group. 28 HOSPITAL NEWS FEBRUARY 2020

success of this program, we anticipate the addition of leadership training opportunities.” Currently consisting of two modules of industry specific courses plus a section devoted to soft skills, such as effective writing and time management, the entire certification is ideal for professionals who want to strengthen their core business, communication and interpersonal skills.

factors that, when compromised, increase the risk of falling. Dr. Hunter is conducting the study at London’s McCormick Dementia Services, Ontario’s largest adult day program, with Dr. Jeff Holmes from the School of Occupational Therapy at Western University; Karen Johnson, Director of McCormick Dementia Services; and Catherine Blake, the Research Coordinator at McCormick Dementia Research. The assessment scale is nearly complete, and Dr. Hunter expects to release it at no cost to health care professionals later this year as an instructional video with online training materials in English, French and Spanish. “This work will allow care planners to identify areas of concern, to determine if there is a need to start therapy to address ongoing problems with balance or walking, or to specifiH cally address any safety issues.” ■

“The intent of this program is to help our Members round out existing skills and add new ones to meet the changing requirements of our hospital stakeholders,” says Marc Lemaire, Chief Procurement Officer and VP Strategic Sourcing at Mohawk Medbuy. “This collaboration with our Members is another great opportunity to maximize our collective knowledge and experiences to drive greater value for our hospitals, which allows them to direct more resources to frontline patient care.” Recognized by the Supply Chain Management Association with applicable Continuing Professional Development credits, the Gold Standard Certification Program follows a two-step learning model consisting of an e-learning component and corresponding inclass sessions. Senior management and content experts from Mohawk Medbuy deliver the in-class training component, creating an interactive, dynamic and engaging opportunity for discussion and knowledge sharing. To date, almost 200 professionals from a wide range of health care organizations have successfully earned their certification. Mohawk Medbuy regularly holds in-class sessions at the company’s Burlington and London offices or on-site at Members’ facilities throughout Ontario and the Maritimes. “The real-life examples, the dialogue, the interactive nature and engagement of the team really helped enhance the learning,” says Jana Kirkpatrick, Director, Strategic Procurement at Services New Brunswick. Due to extraordinarily positive feedback, Gold Standard Certification has a busy roster in 2020. Training took place in Thunder Bay in January and is set to be delivered to more organizations across Ontario, including Chatham, Sudbury and Ottawa, as well as in Prince Edward Island. The goal is to offer in-depth, industry specific information and refresh skills that are used every day. The Mohawk Medbuy Gold Standard Certification Program is open to all Mohawk Medbuy Members and their affiliates. More information can be found by visiting MohawkMedbuy. H ca/gold-standard-certification ■ www.hospitalnews.com

NEWS

Beth Bruce with a Providence stay care program client

Adult day and overnight stay care program cares for seniors and their caregivers By Nikki Jhutti welve years ago, Noreen Peters married the love of her life, Jim. “He’s a fun loving guy, he’s a joker and he has a great sense of humor,” smiles Noreen. “He promised me I would never be bored.” Jim kept that promise. But not in the way the couple imagined. In 2014, Jim was diagnosed with Alzheimer’s disease and vascular dementia. “I finally found someone who loves me unconditionally and he’s going to disappear,” Noreen says holding back tears. Jim is now 81-years-old. The doting wife cares for him full-time and up until recently, she was still working. “He wasn’t safe to stay at home by himself, but I needed to work,” Noreen explains. That’s when she learned about Providence Care’s Adult Day

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PROVIDENCE CARE’S ADULT DAY AND OVERNIGHT STAY CARE PROGRAM PROVIDES QUALITY RESPITE CARE FOR ADULTS LIVING WITH DEMENTIA, ALZHEIMER’S DISEASE OR PHYSICAL DISABILITIES. and Overnight Stay Care program. It provides quality respite care for adults living with dementia, Alzheimer’s disease or physical disabilities. Jim started going to the program in February 2018. “He started one day a week, but he wanted to know why I was working and he wasn’t,” the caregiver explains. “He was retired when I met him, but he said ‘no I’m not retired’. I said ‘OK let me find you job’, so I found him a ‘job’ at the Adult Day program.” Jim now goes to ‘work’ five days a week. “He spends a lot of time in my

office, cleans and helps me out,” says Beth Bruce, program coordinator. “The biggest thing is to allow clients to live in the moment, in their reality. You can’t tell them what to do. You have to figure out where they are in their life.” “My husband needs to see me all the time, but this is one place he agrees to go without me,” adds Noreen. “I was his caregiver 24/7 for five years, but I couldn’t do it anymore. I needed some me time. I know he is safe here and I know he’s entertained.”

The program serves up to 28 clients a day. They range in age from as young as 50-years-old to 102. The staff is made up of personal support workers, a registered practical nurse, recreational and administrative staff, as well as volunteers. “People gather, socialize, take part in games or physical activities, or get care, like have a bath or get their nails cut,” explains Bruce. “It’s respite for caregivers but we also want to help clients maintain their independence. So if we can keep them stimulated, keep their minds and bodies working, they can stay independent and remain in their own homes longer.” Activities vary from week to week, but may include trivia and word games, badminton, music, daily exercise, gardening or baking. Continued on page 31

FEBRUARY 2020 HOSPITAL NEWS 29

SAFE MEDICATION

How to disclose a medication incident to your patient By Grant Fuller and Certina Ho very patient has the tright to be informed when an incident associated with medication therapy has occurred. Healthcare practitioners need to understand when disclosure is appropriate or necessary and how to properly disclose medication incidents. In this article, we will suggest a framework for the disclosure of medication incidents. This framework is adapted from the Canadian Patient Safety Institute (CPSI) “Canadian Disclosure Guidelines” and a previously published continuing education lesson for pharmacy technicians on “How to Handle a Medication Error”. We also consulted the Canadian Medical Protective Association (CMPA) article, “Disclosing harm from healthcare delivery: Open and honest communication with patients”. We would like to refer readers to these original resources for further information.

A SUGGESTED APPROACH TO DISCLOSE MEDICATION INCIDENTS Immediate Actions After a medication incident is discovered, there are immediate actions that must be taken before the disclosure: • Attend to the affected patient(s); ensure their care needs are met. • Take immediate measures to prevent similar safety risks from harming other patients or staff. Is Disclosure of the Medication Incident Needed? After any immediate safety concerns are addressed, practitioners must decide whether disclosing the medication incident to the patient is appropriate or necessary (Figure 1). • Consider the degree of harm the patient experienced or could have reasonably experienced as a result of the incident (Figure 1) • “Harm” refers to incidents that reached the patient and resulted in

• Use appropriate non-verbal gestures (e.g. body language, tone of voice, facial expressions). • Assure that harm did not result from anything the patient or family did or did not do.

Medication Incident

Reached the patient

Did not reach the patient

Patient Harm

No Harm

Near Miss

Always Disclose

Generally Disclose

Generally need not disclose unless ongoing safety risk

Figure 1 – Circumstances When Disclosure is Appropriate or Necessary Reference: Canadian Patient Safety Institute Canadian disclosure guidelines: being open and honest with patients and families; November 2011.

APOLOGIES ARE CRUCIAL TO THE DISCLOSURE PROCESS; THEY MAKE PATIENTS FEEL VALIDATED AND RESPECTED. temporary or permanent impairment (including mental, physical, sensory functions and pain) in body functions or structures • “No Harm” refers to incidents that reached the patient but resulted in no injury • “Near Miss” refers to events that could have resulted in patient harm but did not reach the patient • When in doubt, consider whether a patient would reasonably want to know about the incident.

30 HOSPITAL NEWS FEBRUARY 2020

Apologies Apologies are crucial to the disclosure process; they make patients feel validated and respected. Legislation exists in several provinces, including Ontario, to protect healthcare practitioners from legal liability associated with apologizing. When offering an apology: • Communicate genuine sincerity about the medication incident. • Use a personal tone, including terms, such as, “I” or “We.”

Preparing the disclosure When a disclosure is necessary, prepare for the initial meeting: • Schedule an in-person meeting at the earliest practical opportunity. Select a time that is convenient for the patient and family and a place that is private and free of interruptions. Allow adequate time for discussion of the incident. • The most responsible healthcare provider who is involved should facilitate the disclosure. All others who played a role in the incident should be prepared to discuss relevant events with the patient and family. • Anticipate emotions; both the patient and practitioners should have supports available at the disclosure meeting if needed. • Assign a staff member as the primary contact for the patient and family throughout the disclosure process. Disclosure The initial disclosure provides an opportunity for the patient and family to understand what the medication incident was, why and how it might have happened. • Focus on the events that led to the incident. Use clear and understandable terminology. Avoid speculation and assigning blame. • Encourage the patient and family to discuss the incident from their point of view. • Discuss any changes to the ongoing care of the patient in consultation with the patient’s primary healthcare provider. • Document the discussion. Allow the patient and family to review the documentation to ensure everyone agrees on the facts. www.hospitalnews.com

SAFE MEDICATION Continued feedback Disclosure requires continued dialogue with the patient and family rather than a single discussion. After the initial disclosure meeting and when the medication incident has been fully reviewed and analyzed: • Communicate new findings about the incident to the patient and family members. • Reinforce, update, or correct information provided in previous meetings. • Discuss any improvements or changes made in practice in order to prevent similar events from occurring. • Provide continued practical and emotional support to the patient and family. After a medication incident occurs, the course from reporting and disclo-

sure to the eventual implementation of system-based improvements can be complicated. Having a structured approach and the knowledge to appropriately disclose medication incidents are important; however, they represent just one step in addressing the challenges of medication incident reporting and learning. Improving how we deal with medication incidents will require an ongoing engagement and support from organizations, teams, and individual practitioners. The information in this article is adapted from a recently published article on “Disclosure of Medication Incidents: A Suggested Framework” in the Summer 2019 edition of the Ontario College of Pharmacists (OCP) PharH macy Connection journal. ■

Grant Fuller is a PharmD Candidate at the School of Pharmacy, University of Waterloo. He completed a co-op placement at the Institute for Safe Medication Practices Canada (ISMP Canada) as a Medication Safety Analyst; and Certina Ho is a Project Lead at ISMP Canada.

Adult day and overnight stay care Continued from page 29 “Alzheimer’s and dementia aren’t going away, in fact with this particular population it’s growing,” says Jo-Ann Shotton, program manager. “Our recreational staff works very hard to create a calendar of activities that touches base with the abilities of our clients while meeting their physical, social and cognitive needs. We have different activities going on at the same time, to keep as many people engaged as possible.” The program recently extended its weekday hours and is now open Monday to Friday, from 7 a.m. to 6 p.m. Erin Morgan’s mother Carolyn Dukelow has Alzheimer’s. She attends the program five days a week, and has been a client for about a year. “My mom is a very gentle, loving and caring person. I care for her full-time at home. She lives with my husband and our children,” Morgan says. The caregiver added the expanded hours helps her family maintain a routine, they can manage. “I wouldn’t be able to work full time without it, no way. I can bring her before work, and in

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the evenings I have time to run out and grab groceries, pay a few bills or pickup any medications my mom may need.” Morgan also uses the Overnight Stay Care service for her mom, which provides respite care overnight and on weekends. Caregivers are able to drop off their loved ones at 4:30 p.m. on Fridays and pick them up by 2:30 p.m. Sunday. “With having the level of security in that building, as many staff as they do and all their supports, I’m at a 100 per cent comfort level,” Morgan says. “They treat my mom like they do their own loved ones. That gives me and my family so much peace of mind.” “People say we’re their angels looking after them, when they had no hope at home,” adds Bruce. “It’s very rewarding and makes you feel warm inside. It’s nice to know what we’re doing is helping people.” People like Noreen and Jim Peters. “It was the best decision I made to have Jim come here,” Noreen exclaimed. H “It’s important to recharge. ■

Nikki Jhutti is a Communications Officer at Providence Care. www.hospitalnews.com

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