Hospital News June 2020 by Hospital News

Inside: From the CEO’s Desk | Evidence Matters | Safe Medication | Ethics | Long-term care

June 2020 Edition

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FEATURED

It’s all in the

genome: Preparing for the next waves of COVID-19 Page 16 THANK YOU FOR YOUR HEROIC EFFORTS < We’re so grateful for your tireless efforts and those of your fellow frontline workers as you all work so hard to keep Canadians safe and healthy. We’re staying home so that you too can stay safe! 1-866-768-1477 | www.healthcareproviders.ca

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Reality check. When the threat of COVID-19 emerged earlier this year, there were assurances that our health-care system was ready. Here in Ontario, many believed we had learned the lessons of SARS. But the reality of the pandemic proved otherwise. The consequences of chronic underfunding and unsafe staffing levels are now in plain view. Our long-term care sector is particularly compromised. For years, the Ontario Nurses’ Association has voiced concerns and made recommendations. So have many others. Nurses and health-care professionals will continue to stand on the front lines against COVID-19. More than that, we’re here to contribute our experience and insight to solve the urgent issues facing Ontario’s health-care system, so clearly exposed by the pandemic. Let’s get it right this time.

Vicki McKenna, RN, ONA Provincial President

Contents June 2020 Edition

IN THIS ISSUE:

Home care volunteers ramp up for COVID-19 relief

▲ Cover story: It’s all in the genome: Preparing for the next waves of COVID-19

▲ Doctors without Borders: Covid-19

▲ Compassionate visitation protocols needed during the pandemic

COLUMNS Editor’s Note ....................4 In brief .............................6

From the CEO’s desk .....22 Evidence matters ...........20 Safe medication ............23 Ethics .............................14 Long-term care ...............24

▲ Weeding through new evidence on medical cannabis

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ROSA the robot will help isolated seniors and support aging in place

▲ Non-invasive ventilation mask being tested on tthe frontline

A digital vaccination scar

for the 21st Century By Kumanan Wilson n the 1800s, smallpox ravaged the world. Fortunately, a vaccine had been developed that could protect individuals. This vaccine left a scar at the site of injection and identified the individuals as “immune.” As we look towards the future of the COVID-19 pandemic, unless the virus burns out or an effective therapeutic intervention becomes available, the only way out of our current situation will be immunity – either natural or induced by a vaccine. If so, we will need to create a digital proof of immunity, a digital version of the smallpox scar, to help society to return to normal. Ideally, a safe and effective vaccine will be available in the New Year. If this is the case, we will need to have effective systems in place to identify those who are immunized. Our existing system of largely paper records will not be adequate. Here is how such a system should work. Most provincial/territorial governments have repositories of immunization data. For the eventual COVID-19 vaccine, they will need to ensure that this data is accurate and that the individual identified did, indeed, receive the vaccine. The government could then issue a verified credential, an immunization badge, which contains an easily scannable barcode or QR code, through government portals. This can be consumable by third party apps or be downloaded similar to a boarding pass.

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To enter into certain venues, such as sporting events or for international travel, the digital badge will have to be presented. The bar code will be scanned and matched to an individual’s ID card, just as we do for boarding passes. This will permit entry or travel. Exemptions will exist for medical reasons. I expect our tolerance for philosophical exemptions will be much lower given the consequences on both health and the economy if outbreaks re-emerge. Ideally an international standard for this vaccination will be set under the International Health Regulations which already provide guidance for Yellow Fever vaccine certificates (Annex 7). This guidance needs to take into account the digitization of these certificates. More controversial is the issuance of digital badges for natural immunity confirmed by antibody testing. The science and ethics of this solution are not mature at present but that should not preclude us from considering this option. As for immunization, antibody data from credentialed labs could be stored in immunity repositories and digital badges issued if a threshold of immunity is considered to be achieved. The most likely initial application of this solution will be front-line workers where, if we are confident natural immunity provides protection, we can create systems ensuring certain percentages of front-line workers are identified to be immune. This will create a form of “shield immunity” disrupting the transmission of the virus and protecting front-line workers and the people for whom they care. Continued on page 7

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Monthly Focus: Cardiovascular Care/Respirology/Diabetes/ Complementary Health: Developments in the prevention and treatment of vascular disease, including cardiac surgery, diagnostic and interventional procedures. Advances in treatment for various respiratory disorders, including asthma and allergies. Prevention, treatment and longterm management of diabetes. Examination of complementary treatment approaches.

Monthly Focus: Paediatrics/Ambulatory Care/Neurology/ Hospital-based Social Work: Developments in the prevention and treatment of vascular disease, including cardiac surgery, diagnostic and interventional procedures. Advances in treatment for various respiratory disorders, including asthma and allergies. Prevention, treatment and long-term management of diabetes and other endocrine disorders.

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

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NEWS

The need for more compassionate visitation protocols during the COVID-19 pandemic By Aia Raafat he Canadian Hospice Palliative Care Association launched a campaign to raise concerns around the issue of grief and bereavement as it pertains to COVID-19. The goal is to create a conversation about the need for more compassionate end-of-life visitation protocols that integrate Hospice Palliative Care (HPC) and safely provide patients and their loved ones with comfort as they say goodbye. Most Hospice Palliative Care (HPC) programs have instituted some limitations to end-of-life visitations but have also recognized the importance of “saying goodbye.” Some programs have created guidelines allowing one or two family members to visit at a time and usually with COVID-19 precautions. While certain provinces have taken steps to relax visitation protocols for end-of-life situations, many hospitals and long-term care homes still do not allow family access, even with personal protective equipment (PPE). In response to inconsistent and in some cases extreme restrictions on end-of-life visitations across Canada during the COVID-19 pandemic, the Canadian Hospice Palliative Care Association (CHPCA) and the CHPCA Champion’s Council are calling on health authorities to implement a more compassionate approach. Every Canadian deserves the chance to say goodbye to their loved ones, even in an unprecedented crisis such as COVID-19. There have been too many heartbreaking stories of families who were unable to say goodbye due to extreme restrictions on end-of-life visitations. While health and safety must continue to be paramount as we fight COVID-19, we can do better as a society by promoting a more compassionate, inclusive visitation protocol that embraces hospice palliative care principles and dying with dignity. “Together, these recommendations will help Canadians say goodbye and deal with their loss in a way that protects the safety of frontline health care workers and prevents transmission of

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COVID-19,” added Russell Williams, chair of the CHPCA’s Champion’s Council. “We look forward to collaborating with health care providers on this important issue.” The CHPCA, which serves as the Secretariat for the Quality End of Life Care Coalition of Canada (QELCCC), is urging health authorities and providers to deliver on three key asks: • Adopt a compassionate protocol that allows those nearing death to say goodbye to their families and loved ones, and follows safety measures including PPE requirements as indicated by the Public Health Agency of Canada. This can be achieved by reviewing current public health protocols to include a compassionate approach around end-of-life visitations. • Liaise with the hospice palliative care (HPC) community to exchange expertise in caring for the dying and the bereaved. Many of the approximately 265,000 Canadians who die each year are supported by HPC, so the CHPCA and its partners have extensive experience in this area and valuable learnings to share. • Offer grief and bereavement support services for those who lose a family member or loved one. Existing grief and bereavement services are extremely limited and not necessarily funded by the health care system.

There are significant long-term implications Canada could face if growing demand is not addressed.

ABOUT THE CANADIAN HOSPICE PALLIATIVE CARE ASSOCIATION

The CHPCA is the national voice for Hospice Palliative Care in Canada. Advancing and advocating for quality

end-of-life/hospice palliative care in Canada, its work includes public policy, public education and awareness. Established in 1991, its volunteer Board of Directors is composed of hospice palliative care workers and volunteers from Canadian provinces and territories as well as members-at-large. For more information, visit https://www.chpca.ca/ H campaigns/saying-goodbye/ ■

Aia Raafat is a Communications officer at the Canadian Hospice Palliative Care Association.

JUNE 2020 HOSPITAL NEWS 5

IN BRIEF

Wait times cost Canadian patients

more than $2 billion in lost wages before COVID-19 ong waits for surgery and medical treatment cost Canadians almost $2.1 billion in lost wages and productivity last year, finds a new study released by the Fraser Institute, an independent, non-partisan Canadian public policy think-tank. And those costs could increase now that many provinces have postponed elective (or scheduled) surgeries as a result of COVID-19. “Health-care workers across Canada should be commended for the superb job they’re doing to get us through this global pandemic. However, once elective surgeries resume, they could face further challenges as they tackle the ever-increasing backlog of patients waiting for care,” said Bacchus Barua, associate director of health policy studies at the Fraser Institute and co-author of The Private Cost of Public Queues for Medically Necessary Care, 2020.

Average value of time lost during the work week in 2019 for patients waiting for medically necessary treatment (by province): British Columbia ............ $1,776 Alberta ........................... $2,834 Saskatchewan ............... $2,421 Manitoba........................ $3,011 Ontario ........................... $1,408 Quebec ........................... $1,381 The study finds that even before the COVID-19 pandemic, more than one million Canadian (1,064,286) patients waited for medically necessary treatment last year, and each lost an estimated $1,963 (on average) due to lost wages and reduced productivity during working hours. Across Canada, the costs of waiting for medical care were about $2.1 billion. The study draws upon data from the Fraser Institute’s Waiting Your

New Brunswick .............. $2,679 Nova Scotia.................... $2,386 Prince Edward Island ............................. $2,856 Newfoundland and Labrador ........................ $2,421

Turn study, an annual survey of Canadian physicians who, in 2019, reported a median wait time from specialist appointment to treatment of 10.8 weeks – three and a half weeks longer than what physicians consider clinically reasonable. Crucially, the $2.1 billion in lost wages is likely a conservative estimate because it doesn’t account for the additional 10.1-week wait to see a specialist after receiving a referral

from a general practitioner. Taken together (10.1 weeks and 10.8 weeks), the median wait time in Canada for medical treatment was 20.9 weeks in 2019. “Even before we started postponing surgeries as a result of COVID-19, patients across Canada were waiting a significant amount of time, and long health-care wait times mean lost wages and a reduced quality of life for patients,” Barua said. “Now is the time to consider policy options that may benefit patients and alleviate strain on our public health-care system once the COVID-19 crisis has run its course.” Because wait times and incomes vary by province, so does the cost of waiting for health care. Residents of Manitoba in 2019 faced the highest per-patient cost of waiting ($3,011), followed by P.E.I. ($2,856) and AlH berta ($2,834). ■

Study finds temperature, latitude not associated with COVID-19 spread emperature and latitude do not appear to be associated with the spread of coronavirus disease 2019 (COVID-19), according to a study of many countries published in CMAJ (Canadian Medical Association Journal), but school closures and other public health measures are having a positive effect. “Our study provides important new evidence, using global data from the COVID-19 epidemic, that these public health interventions have reduced epidemic growth,” says Dr. Peter Jüni, Institute for Health Policy, Management and Evaluation, University of Toronto, and St. Michael’s Hospital, Toronto, Ontario. The Canadian study looked at 144 geopolitical areas – states and provinces in Australia, the United States and Canada as well as various countries

6 HOSPITAL NEWS JUNE 2020

around the world – and a total of more than 375 600 confirmed COVID-19 cases. China, Italy, Iran and South Korea were excluded because the virus was either waning in the case of China or in full disease outbreak at the time of the analysis in others. To estimate epidemic growth, researchers compared the number of cases on March 27 with cases on March 20, 2020, and determined the influence of latitude, temperature, humidity, school closures, restrictions of mass gatherings and social distancing measured during the exposure period of March 7 to 13. They found little or no association between latitude or temperature with epidemic growth of COVID-19 and a weak association between humidity and reduced transmission. The results – that hotter weather had no effect on the pandemic’s progression – surprised the authors.

“We had conducted a preliminary study that suggested both latitude and temperature could play a role,” says Dr. Jüni. “But when we repeated the study under much more rigorous conditions, we got the opposite result.” The researchers did find that public health measures, including school closures, social distancing and restrictions of large gatherings, have been effective. “Our results are of immediate relevance as many countries, and some Canadian provinces and territories, are considering easing or removing some of these public health interventions,” says Dr. Jüni. “Summer is not going to make this go away,” says Prof. Dionne Gesink, a coauthor and epidemiologist at Dalla Lana School of Public Health. “It’s important people know that. On the other hand, the more pub-

lic health interventions an area had in place, the bigger the impact on slowing the epidemic growth. These public health interventions are really important because they’re the only thing working right now to slow the epidemic.” The authors note several study limitations, such as differences in testing practices, the inability to estimate actual rates of COVID-19 and compliance with social distancing. When deciding how to lift restrictions, governments and public health authorities should carefully weigh the impact of these measures against potential economic and mental health harms and benefits. “Impact of climate and public health interventions on the COVID-19 pandemic: a prospective cohort study” was published H May 8, 2020. ■ www.hospitalnews.com

IN BRIEF

Fatal Lyme carditis in a 37-year-old man illustrates need for awareness of atypical presentations of Lyme disease yme disease can have unusual presentations. Physicians and the public should be aware of its different manifestations, as people spend more time outside in the warmer weather and as the areas in Canada where the black legged tick is found expand. Three articles in CMAJ (Canadian Medical Association Journal), which describe a fatal case in a 37-year-old man, atypical skin lesions and heart abnormalities in a 56-year-old woman and severe neurological symptoms in a 4-year-old boy, illustrate the diversity in clinical presentations of Lyme disease. Lyme disease can affect the heart (known as Lyme carditis), which can result in serious heart rhythm abnormalities in a small group of people. Clinicians should be aware of the possibility of Lyme carditis in people presenting with atrioventricular heart block, especially in areas where Lyme disease is endemic. Patients may have had a rash. Early treatment with anti-

biotics is recommended to avoid complications, even before a diagnosis is confirmed A fatal case of Lyme disease in a previously healthy 37-year-old man illustrates the challenges of diagnosing Lyme disease in the absence of classic symptomsThe patient originally presented to his family doctor with flulike symptoms, including fever, sore throat, nasal congestion and migratory joint pain. Several weeks earlier, he had been in contact with ticks but didn’t recall removing one. His physician suspected a viral infection, and the patient’s symptoms resolved. Weeks later, he developed heart palpitations, shortness of breath and chest discomfort for which he was sent to the emergency department. Lyme disease was suspected as electrocardiography (ECG) showed complete heart block. He was admitted to hospital and started on treatment for Lyme carditis, but his condition worsened quickly. Clinicians were unable to reverse the course of illness and he

died. Serology results confirmed Lyme disease, and an autopsy showed signs of Lyme carditis. “The diagnosis of Lyme carditis is based on clinical suspicion and serology consistent with acute Lyme disease,” writes Dr. Milena Semproni, Infectious Diseases fellow at the University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, Manitoba, with coauthors. “Unfortunately, diagnosis can be delayed while serology is being processed, and clinical suspicion should guide empiric treatment. Given that the early diagnosis is clinical, cases may be overlooked by clinicians, especially as Lyme disease moves into new geographic areas.” In suspected cases of Lyme carditis, patients should have an urgent ECG performed and be started on antibiotics without waiting for serologic confirmation. The authors note that serious heart rhythm abnormalities and sudden cardiac death can occur in a small group of patients, although it is uncommon.

Physicians need to address increased intimate partner violence during and after COVID-19 ntimate partner violence has increased during COVID-19 isolation. Therefore, health care providers should be aware of the signs of intimate partner violence and learn strategies to safely ask about injuries, argues a commentary in CMAJ (Canadian Medical Association Journal). “Measures to minimize the spread of severe acute respiratory syndrome coronavirus 2 reinforce environments that facilitate behaviours that an intimate partner may use to exert power over another to inflict psychological, physical or sexual harm,” says Dr. Prism Schneider, Cumming School of Medicine, University of Calgary, Calgary, Alberta. “The stress of confinement, financial uncertainty, attitudes about gender roles and a desire for control during disasters all contribute to an increased risk of intimate partner violence.”

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China, Italy and Spain have reported increases in calls to emergency support lines; some areas of the United Kingdom and France have had police reports of violence increase by 20 and 30 per cent, respectively; and crisis lines in Canada have seen large jumps in the number of calls. The frequency of intimate partner violence increased markedly during the economic downturn after Hurricane Katrina, suggesting that those affected will continue to be at risk long after the current phase of the pandemic ends. “Health care providers, although facing the need to learn many new skills related to COVID-19, must also maintain awareness of intimate partner violence, seek opportunities for self-education, develop strategies for discussing intimate partner violence and become familiar with currently available local resources for patient referral,” write the authors.

One in three women visiting an emergency department for trauma has been injured by her partner, and orthopaedic clinics also see large volumes of patients who have experienced intimate partner violence. Evidence supports direct questioning by a health care provider in a private environment if they suspect injuries from violence, as many women will not offer this information without prompting. “The onus is on health practitioners to begin the conversation with patients who may have experienced intimate partner violence,” write the authors. As many physicians have moved to telemedicine consults to maintain physical distancing, Canada has launched a “Safe Word” campaign and a “Signal for Help” campaign for patients to send a silent request for help. “Health care practitioners’ responsibility to address intimate partner violence related to the COVID-19 H pandemic” is published May 1, 2020. ■

In the 10 other North American cases of sudden cardiac death attributed to Lyme carditis described in the literature, 8 patients were male, and the cases occurred between June and November, when ticks are active. “Given that most conduction abnormalities caused by Lyme carditis resolve with appropriate antibiotic therapy, recognition of atypical dermatologic presentations in the context of Lyme carditis prevents unnecessary permanent pacemaker implantation in these young and otherwise healthy individuals,” writes Dr. Adrian Baranchuk, Department of Medicine, Queen’s University, Kingston, with coauthors. While the bull’s eye rash is usually considered a feature of Lyme disease, in some cases, the rash doesn’t follow H the usual pattern. ■

Digital vaccination

Continued from page 4 A digital solution will have security and privacy risks that a paper record won’t have. However, a digital solution will be agile and adaptable in a way paper records cannot be. For example, if scientific evidence emerges on waning immunity, digital badges can be revoked. Decentralized ledgers (think blockchain) can facilitate the movement of this information across borders and between institutions. As we enter into the next stage of this pandemic, we must start taking steps to ensure we have the right technology in place when science provide us with solutions. I have confidence that the combination of science and technology with ethical and legal oversight can accelerate H our return to normal. ■ Kumanan Wilson, MD, MSc, FRCPC, is a physician at The Ottawa Hospital and a member of the University of Ottawa Centre for Health Law, Policy and Ethics. He has been a consultant to the World Health Organization on the IHR (2005). JUNE 2020 HOSPITAL NEWS 7

SPONSORED CONTENT

Coping with COVID-19

How Microsoft technologies are enhancing hospitals’ response his year, the unprecedented arrival of the COVID-19 pandemic forced healthcare organizations to up their intelligence game – quickly. As part of that response, Microsoft technology is providing Canadian healthcare organizations with information solutions that allow for safety, better experiences, health insights, and virtual care. “Microsoft realizes healthcare leaders are under tremendous pressures to respond to the crisis of COVID-19 – to keep frontline workers safe, support the reduction of the community spread, and provide unprecedented emergency care response and capacity for those who contract the disease,” says Lisa Carroll, Microsoft Canada’s Canadian Public Sector Lead. “It is crucial for them to have accurate, secure, and readily accessible data in order to make informed decisions and prioritize resources.” Microsoft is committed to meeting COVID-19-related demands through effective tools such as Azure, Teams, and Power BI dashboards, which securely connect health data and systems in the cloud.

TORONTO UNIVERSITY HEALTH NETWORK In Canada’s largest city, the multisite University Health Network (UHN) provides a case study in the rapid adaptation of Microsoft technology to the pressing information needs triggered by the COVID-19 pandemic. UHN has leveraged Microsoft Power BI data visualization tools to build a single-page intelligence canvas that instantly turns complex data from multiple data sources into colourful eye-friendly charts, graphs, and maps easily grasped at a glance. UHN is using this analytics tool to track internal COVID-19 information, including site-specific patient intake and availability of resources such as bed capacity, ventilators, personal protec-

MICROSOFT TECHNOLOGY IS PROVIDING CANADIAN HEALTHCARE ORGANIZATIONS WITH INFORMATION SOLUTIONS THAT ALLOW FOR SAFETY, BETTER EXPERIENCES, HEALTH IN SIGHTS, AND VIRTUAL CARE. tive equipment, and testing. “UHN is leveraging Power BI to connect disparate data from across the organization into one single source of truth to garner business intelligence and make real-time data-driven decisions,” Carroll says. Michael Caesar, UHN’s executive director of data and implementation science, expands. “We knew we had to pivot quickly to support our workers and enable executive leaders with meaningful insights to see what was happening across the organization. Within a week and a half, our data team was able to create a dashboard that gave us a real-time view of the impact of the pandemic and how it made us deviate from our normal operations.” Power BI allowed UHN to tap into the lab and see how many people were testing positive and how many did not meet testing criteria. “It also gave us a real-time view into the emergency room volumes, how many people were in isolation and of these how many were COVID-19 patients,” he says. According to Caesar, the dashboard revealed that UHN’s usual inpatient occupancy of up to 110% capacity quickly dropped to as low as 70%, while in-person outpatient appointments fell from typically 5,000 a day to as low as 1,500, while virtual care appointments spiked almost overnight. And although ER volumes fell, COVID-19 patients were requiring more care, including isolation, intubation, and monitoring. Pulling data from all departments, Power BI revealed one integrated pan-network picture of the virus’s operational impact. “Leadership could see in real time and through a

COVID-19 lens that the world was changing right before their eyes,” Caesar says. By monitoring availability of of critical supplies such as gowns, masks, sanitizers and gloves, Power BI allowed executives and supply chain management to plan together for shortfalls. “We were planning for critical shortages of our personal protective equipment,” says Rebecca Repa, UHN’s executive vice president of clinical support and performance. “We were able to show rate of utilization and focus our procurement and conservation attention to those areas of greatest risk.” As the pandemic grew exponentially, Power BI provided invaluable intelligence on frontline workers’ exposure to infection, quickly visualizing lab results and positive tests. “The dashboard gives incredible insight not only into how we are doing with staff testing but also the results of our tracing efforts, says Dr. John Granton, UHN’s division head of respirology and interim medical director of occupational health. And looking ahead, having instant access to rapidly changing data and shifting realities is also facilitating the predictive modelling and scenarios testing needed to plan for future capacity, resources, and supplies.

THE OTTAWA HOSPITAL The pandemic rapidly cast the need for secure co-ordinated communication into sharp focus, a need that Microsoft Teams, a chat-based collaboration tool allowing remote teams to share information in a safe common hub, is designed to meet.

Within a matter of weeks, the COVID-19 crisis swelled the number of active users of the Microsoft Teams platform at The Ottawa Hospital (TOH) from 3,000 to 10,000. The collaboration tool is enabling clinicians and other staff across the four hospitals and their affiliated clinics to work together, even though apart, through the platform’s video conferencing, secure instant messaging, group communications, and document sharing. TOH was also quick to establish a Power BI dashboard providing a comprehensive view of bed capacity across all hospitals in the region and allowing better management of patient flow and occupancy. “You just can’t believe how much more in a good place we are in coping with COVID-19 because we are properly and extensively leveraging Microsoft technologies,” says Shafique Shamji, TOH’s executive vice president and chief information officer. “The capabilities and velocity we now have has made us much better equipped to handle the new reality.” New care teams are now supporting different crisis-related initiatives such as the COVID-19 Assessment Centre Teams site, a collaboration between TOH and several partners now testing hundreds of patients a day. “Everyone uses their own corporate accounts and it works flawlessly,” says Shamji. “This technology was key in enabling the organization to collaborate both internally and across different organization to help the reduction of the spread of the virus and save lives.” Although these platforms are being quickly adopted as hospitals recognize the clear benefits of moving from discrete, silo-style data repositories to shared accessibility, UHN’s Caesar acknowledges some effort is still needed across the industry to encourage full participation. “It’s a cultural thing, a comfort thing, and we need to continue to work on it,” he says. “But we were able to showcase the art of H the possible in bringing data forward.” Q

See how Microsoft is empowering hospitals to continue to provide even better experiences, insights and care: Visit aka.ms/healthcareincanada 8 HOSPITAL NEWS JUNE 2020

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NEWS

Compassionate leadership guiding response to COVID-19 By Johny Van Aerde and Carol Rochefort ompassion, teamwork and even allowing the capacity for failure are important guiding principles for many of the physicians leading the response of hospitals and health regions to the COVID-10 pandemic. Since dealing with the pandemic became a priority in early April, the Canadian Society of Physician Leaders has been producing a series of podcasts – Leading the Way – featuring short interviews with Canadian doctors providing leadership in a variety of settings. While one would assume the “command and control” style of leadership would be seen as the dominant style favored by these individuals in the response of their hospital or health region to the pandemic in fact the opposite is true. Many of those interviewed identified leadership in support of others – “servant leadership” – and teamwork as overarching guiding principles. Typical of this perspective was the approach taken by Dr. Gillian Kernaghan, President and CEO of St. Joseph’s Healthcare in London, ON. “Although, in a pandemic or any crisis, you tend towards a bit more command and control, you recognize that you need to rely on a lot of people,” she said. She added that hospital CEOs must delegate and trust people and build “a strong team of people that you can work together with, to make sure, that there’s cohesion and consistency in the response across your organization.” She said leaders within the institution who have taken the time to build strong relationships in their departments are seeing a payoff during the pandemic because of the trust that has developed. Dr. Verna Yiu, President and CEO of Alberta Health Services referenced

compassionate leadership and the need to recognize these are not normal times and provide mutual support. Even within the political sphere, building consensus rather than command and control has been the driving force in responding to the pandemic, according to Dr. John Haggie, Minister of Health and Community Services in Newfoundland and Labrador. The basis for decisions in dealing with the pandemic “are often more consensus based than people would realize,” he said. The need for teamwork was also a theme that emerged repeatedly in the interviews. “I personally believe that leadership is fundamentally about improving the performance of the team that you lead or the team that you’re a

part of. And the reality is that healthcare is a team sport,” said Dr. Scott McLeod, Registrar of the College of Physicians and Surgeons of Alberta. “Every member of that team … has an opportunity to improve the performance of the team. And that may just simply be helping out a colleague or making life easier on the nurses working beside you.” “Managing team members, thanking team members, making sure that they’re well cared for and that they’re getting their rest and the resources they need to be able to do the job is also fundamental to being able to achieve success,” said Dr. Dave Williams, retired President and CEO of Southlake Regional Health Centre and a former astronaut. Dr. Williams also talked about the need for leaders

to have the “emotional awareness and sensitivity” to appreciate the stress all hospital workers are currently under. Dr. Joshua Tepper, President and CEO of North York General Hospital also talked of the need for leaders to look after their own wellbeing and to not be afraid to make mistakes during these times. “Leadership is always a hard and taxing role (and) at this time, even more so…Please take the time to selfcare, be gentle on yourself and treat yourself with some kindness. We’re working fast and we’re working hard and we’re working in unprecedented times. And we’re going to make mistakes. You know, maybe there’s leaders out there who haven’t made a mistake in the last six weeks. I’m not one of them. I’ve made plenty in the last few weeks. I think we need to acknowledge them, try to learn from them (and) grow from them. Dr. Haggie and others interviewed touched on how the healthcare system will change after COVID-19. “I think the idea of having a centre of excellence as a building on a hill is a thing of the past. People will want care in their own front room and if not, then as near to their own front room as possible.” Dr. Tepper talked maintaining awareness of the need to support the health and wellbeing of providers. “Let’s be clear, the data was incredibly strong before the pandemic about how much stress healthcare providers were under already. So, it’s not like people were in a great state and then the pandemic came. There was already a high rate of burnout, depression, suicide, and substance use disorder compared to the rest of the population. We have to make sure that the type of focused attention we’ve been paying in the pandemic is H really continued afterwards.” ■

Dr. Johny Van Aerde MD, PhD is the Executive Medical Director and Carol Rochefort CAE, is the Executive Director of the Canadian Society of Physician Leaders – www.physicianleader.ca 10 HOSPITAL NEWS JUNE 2020

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P R O G R A M

O F

T H E

NEWS

Canadian team first in the world to treat covid-19 with

specialized dialysis By Robert DeLaet s part of a randomized controlled trial, a team from Lawson Health Research Institute is the first in the world to treat a patient with COVID-19 using a modified dialysis device. The device gently removes a patient’s blood, modifies white blood cells and returns them to fight hyperinflammation. It is being tested with critically ill patients at London Health Sciences Centre (LHSC). Evidence suggests that COVID-19 causes a heightened immune response, termed a ‘cytokine storm,’ in the most severely ill patients. Treatment options to address this hyperinflammatory state are currently limited and there are concerns about global drug shortages. “Working in the intensive care unit (ICU), I was aware that more treatment options were needed in the fight against COVID-19,” says Dr. Chris McIntyre, lead researcher, Lawson Scientist and LHSC Nephrologist. “This led to the idea of treating

a patient’s blood outside of the body. We could reprogram white blood cells associated with inflammation to alter the immune response.” The research uses a modified version of a standard dialyzer called an extracorporeal leukocyte modifying device. It gently removes blood in a much slower circuit than standard dialysis. Through a process using specific levels of biochemical components, it targets and transforms white blood cells associated with inflammation before releasing them back into circulation. The hope is that these ‘reprogrammed’ cells will now fight hyperinflammation – rather than promoting it - in affected organs like the lungs. The clinical trial will Include up to 40 critically ill patients with COVID-19 at LHSC’s Victoria Hospital and University Hospital. Research participants will be randomized to receive either standard supportive care or standard supportive care in combination with this novel treatment. The research team will compare

Dr. Chris McIntyre, Scientist at Lawson Health Research Institute and Nephrologist at London Health Sciences Centre, is the first in the world to treat a patient with COVID-19 using a modified dialysis device. patient outcomes to determine if the treatment is effective. “The ultimate goal is to improve patient survival and lessen their dependency on oxygen and ventilation,” explains Dr. McIntyre. “If effective, it’s possible that this treatment could be combined with other therapies. For example, this could be used to modulate inflammatory consequences while an antiviral drug is used to reduce the viral load.” Led by Lawson’s Kidney Clinical Research Unit, this new trial was accelerated from initial conception to treatment of the first patient in only 40 days. It represents an important research collaboration with a multidisciplinary team. The trial is leveraging in-

sights gained from another local study led by Dr. Douglas Fraser which is analyzing blood samples from COVID-19 patients at LHSC to better understand the cytokine storm. “We’re identifying which cytokines or biomarkers are important to the hyperinflammatory response seen in COVID-19 patients,” says Dr. Fraser, Scientist at Lawson and Paediatric Critical Care Physician at LHSC. “With the knowledge we’re gaining, we can study a patient’s blood to determine whether this extracorporeal treatment is making a difference.” If successful, the treatment also has potential to be used with other condiH tions like sepsis. ■

Robert DeLaet works in Communications & External Relations at Lawson Health Research Institute.

Diagnosing COVID-19 using artificial intelligence By Emilly Dubeau esearchers at Lawson Health Research Institute are investigating whether an artificial neural network could be used to diagnose COVID-19. The AI system is being trained to learn and recognize patterns in ultrasound lung scans of patients with confirmed COVID-19 at London Health Sciences Centre (LHSC) by comparing them to ultrasound scans of patients with other types of lung infections. “Machines are able to find patterns that humans cannot see or even imagine. Lung ultrasound scans of patients with COVID-19 pneumonia produce a highly abnormal imaging pattern. This

MACHINES ARE ABLE TO FIND PATTERNS THAT HUMANS CANNOT SEE OR EVEN IMAGINE. pattern isn’t unique to COVID-19, and can be seen in other causes of pneumonia. It is plausible, however, that there are details that distinguish COVID-19 at the pixel level that cannot be perceived by the human eye,” explains Dr. Robert Arntfield, Lawson Researcher and Medical Director of the Critical Care Trauma Centre at LHSC.

Point-of-care ultrasound has become increasingly important for the care of critically ill patients and LHSC is a global leader in the use of this technology at the bedside. Lung ultrasound has proven to be effective in diagnosing different types of lung infections and illnesses, such as pneumonia, with a high degree of accuracy. The convenience, portability and low cost of using these machines has helped them become a standard bedside tool in emergency departments and intensive care units worldwide. This research project is part of a grassroots effort by a small group of local clinicians to innovate and create technology to solve sophisticated problems with AI. With many of Dr.

Arntfield’s team having a background in computer programming, they were able to code the neural network being tested. Minimal funding was required, with the project being driven largely by the urgency of COVID-19 coinciding with the recent creation of this clinical AI working group. “Our research team has used AI to help improve diagnostics related to other parts of the body. This project is a great example of the unique ability we have here in London to be agile: that is, to identify a gap and move quickly towards finding a solution,” says Dr. Arntfield. “I am thrilled that we were able to move through the approval process quickly, and get our ideas working H in such a short amount of time.” ■

Emilly Dubeau is a Consultant, Communications & External Relations at Lawson Health Research Institute. 12 HOSPITAL NEWS JUNE 2020

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ETHICS

Changes in visitor policies

during COVID-19

By Andria Bianchi and Katherine Stanley s a result of COVID-19, several practices and processes in healthcare settings have changed. One change that has had a substantial influence on patients, families, and healthcare providers is that of hospital visitor policies. Typically, hospitals and other healthcare facilities (e.g. long-term care) allow inpatients to be visited by loved ones each day and outpatients to be accompanied by support persons for appointments. In light of COVID-19, however, visitor policies have been altered in order to protect healthcare workers, patients, and families from COVID-19 transmission. At the present time, most patients are unable to bring others with them to outpatient appointments and most inpatients are required to remain in-hospital by themselves. While the newly developed visitor policies differ depending on the healthcare facility, one common element is that every organization has had to put restrictions in place. The decision to restrict visitors in healthcare facilities was motivated by the important need to prevent the greatest number of people possible from being infected by COVID-19. Consequently, however, some unfortunate circumstances have occurred as a result of these visitor policy changes. One of these circumstances, is that most inpatients and outpatients are required to attend medical treatments/appointments without a support person by their side. For example, a person battling cancer may have to attend their first chemotherapy infusion by themselves; a new mother may have to welcome their baby into the world in a way that they did not envision; and a person may have to recover from a surgery without their system support in sight.

MANY HEALTHCARE FACILITIES ARE HELPING TO ARRANGE VIRTUAL MEETINGS AMONGST PATIENTS AND THEIR LOVED ONES. Additionally, some patients in palliative care have been unable to see their loved ones in-person prior to their death, which is both challenging for the patient and for those who wish to say â&#x20AC;&#x2DC;goodbyeâ&#x20AC;&#x2122; in-person. While some facilities do allow actively dying patients (i.e., those who are expected to die within a certain number of days or hours) to have visitors, it is plausible that many of these patients may no longer be conscious and/or able to meaningfully communicate at this stage. In response to the current context, many healthcare facilities are helping to arrange virtual meetings amongst patients and their loved ones so that they can continue to maintain import-

ant social connections. These virtual meetings are proving to be a helpful alternative option for many patients, such that they may be worth using under normal circumstances, especially for patients who do not have in-person support available. Many patients travel significant distances in order to receive specialized care, and it is sometimes impossible to have others attend appointments given the distance(s) travelled. Moving forward and once COVID-19 resolves, perhaps more patients can receive support from afar via the technology platforms that we are presently using. Alongside the noteworthy benefits being experienced by patients and families who are using technology to

connect, some clinicians working in the field have also highlighted limitations. For instance, some patients may not own the technology required to commence their own virtual meetings (and not every healthcare facility has devices available to lend). Many patients may also feel uncomfortable sharing private health information with their loved ones over technological devices. Additionally, patients with communication challenges may be unable to effectively communicate via the devices and/or platforms available. And finally, some patients (e.g. older patients in long-term care facilities) may be unable to recognize their loved ones if they are not physically present. Ultimately, everyone is doing their best during this time; healthcare leaders and providers are working tirelessly to limit COVID-19 transmission and patients and families are finding alternate ways to connect. It is difficult to make ethically defensible decisions in short timeframes and when dire consequences are present, and so decision-makers in healthcare have tried to ensure that the greatest number of people are protected and the least number of people are harmed. At the same time, they have put measures in place, such as virtual meetings with loved ones, to help alleviate some of the challenges that patients and families may be experiencing. Many of these measures may be worth maintaining after COVID-19 in order to provide greater access to clinical and personal care supports. If this occurs, then we ought to consider ways to mitigate the challenges so that we can all benefit. The current crisis and the change in visitor policies have certainly confirmed that individual well-being requires more than just physical H health. â&#x2013;

Andria Bianchi, PhD, is a Bioethicist at the University Health Network; Katherine Stanley, BScN, is a Registered Nurse at the University Health Network. 14 HOSPITAL NEWS JUNE 2020

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COVER

It’s all in the genome: Preparing for the next waves of COVID-19 By Dr. Samira Mubareka n January 24th, Sunnybrook Health Sciences admitted the first Canadian patient with COVID-19. The traveller had just returned from Wuhan, China, the epicentre of the virus outbreak. He presented with a respiratory illness due to SARS-CoV-2, the coronavirus that causes COVID-19. At that moment I realized this virus would come to dominate our reality, both at Sunnybrook and across Canada. I also understood that we needed to move quickly to understand this highly unpredictable virus that had landed on our doorstep, after spilling over to humans from an unknown source and gaining a global foothold. Within six weeks of our first case, in partnership with colleagues at McMaster University, we had isolated the virus from a clinical sample in a high-containment University of Toronto laboratory. Within a week of culturing the virus, we had sequenced the whole genome of our SARS-CoV-2 isolated at Sunnybrook. Sequencing helps us understand how the virus is moving, changing, and being transmitted across the country. It is also critical to pinpointing where the importations come from, and at what point the virus starts spreading locally. The cornerstone for this is good public health and contact-tracing, for which sequencing provides important insights. The need for larger-scale sequencing efforts of SARS-CoV-2 was obvious early on. Sequencing is not usually done at the hospital level, though early adopters such as Sunnybrook are able to sequence 50-100 virus samples per week. As the case counts outran us, a provincial, as well as a national, coordinated response was sorely needed. Without this, we were going to remain blind to how the virus was moving around Ontario and Canada. A $40 million investment by the Government of Canada in late April established CanCOGeN (Canadian

Dr. Samira Mubareka

COVID Genomics Network), an open, collaborative sequencing initiative to coordinate data sharing and analysis across Canada and with international colleagues. Led by Genome Canada, CanCOGeN brings together the National Microbiology Lab, provincial public health labs, hospitals, universities, the six regional Genome Centres, the private sector, and CGEn (national platform for sequencing and analysis). CanCOGeN supports two key projects. The first will sequence up to 150,000 viral samples from people testing positive for COVID-19. Studying the genome of the virus and collectively developing and standardizing lab tools to analyze its traits across Canada will provide critical information for our public health response. The streamlining of guidelines, protocols, and data quality will strengthen and accelerate the response. The second project will sequence the genomes of up to 10,000 patients

diagnosed with COVID-19 (the “hosts”). The number one question that colleagues ask me in the hallways at Sunnybrook Hospital is why there are so many differences (and anomalies) in patient outcomes. Here in Canada, despite the lethality of the virus in our senior population overall, we have seen some elderly patients do exceptionally well and extremely serious symptoms among young healthy people. I am hopeful that by sequencing the genomes of thousands of COVID-19 positive patients we will understand the host genome in the context of viral infection and severity of disease. That will help drive a precision medicine approach during the next waves of COVID-19. Doctors and researchers will be able to more accurately predict which treatment and prevention strategies will work on which groups of people, allowing for individually tailored treatments based on genetic profile.

CanCOGeN will also investigate if and how a virus reinfection can be distinguished from a relapse due to the primary infection. If we sequence the virus collected from a patient during the first infection and compare it to one collected from that same patient during the second infection and they are the same, it is probably a relapse. If they are different, it may be a reinfection. A virus does not respect borders. That’s why sharing quality data across Canada and internationally is crucial. In addition to depositing the sequence data and associated patient data in global public databases, CanCOGeN is collaborating with the COVID-19 Genomics UK consortium and pursuing similar agreements with other countries. These partnerships will allow us to share insights and discoveries to drive understanding of the pandemic as it changes over time. Continued on page 18

Dr. Samira Mubareka is an Infectious Diseases Physician & Virologist - Sunnybrook Health Sciences Centre & Research Institute and the University of Toronto. 16 HOSPITAL NEWS JUNE 2020

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I.C.R.A. WE MEAN IT Infection Control Risk Assessment.

Now, More Than Ever.

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COVER

Non-invasive ventilation mask being tested on the frontline By Robert de Laet ed by Lawson Health Research Institute, London Health Sciences Centre (LHSC), University Health Network (UHN) and General Dynamics Land Systems-Canada (GDLS-Canada), researchers have designed a non-invasive ventilation mask that could significantly reduce aerosolization – the production of airborne respiratory droplets that may contain viruses or bacteria – when treating patients with COVID-19. The new device aims to reduce infection risks associated with non-invasive ventilation and lessen the demand for invasive ventilators. It is currently being tested through a clinical trial with patients at LHSC. “Since the beginning of this pandemic, there have been global concerns about a shortage of ventilators,” says Dr. Tarek Loubani, Lawson Associate Scientist and Emergency Department Physician at LHSC. “Non-invasive ventilators like CPAP (continuous positive airway pressure) and BiPAP (bi-level positive airway pressure) machines are associated with an increased risk of COVID-19 transmission and so many hospitals have moved directly to invasive ventilation.” COVID-19 is primarily spread through inhalation of respiratory droplets and the most severely ill patients require a ventilator to help them breathe. Unlike invasive ventilators, which require intubation, non-invasive ventilators help patients breathe through a mask that provides positive pressure to keep the lungs open and functioning. While non-invasive ventilators may be effective for some COVID-19 patients, their use comes with a much higher risk of spreading infection through aerosolization of respiratory droplets. The team’s non-invasive ventilation mask aims to eliminate this risk. The novel device is customized from a standard firefighter’s mask using 3D printing and can be attached to any CPAP or BiPAP machine. Unlike traditional

Researchers have designed a non-invasive ventilation mask that could significantly reduce aerosolization. masks, it creates two tight seals – one around the patient’s nose and mouth and another around the face. Patients breathe in and out of a filter that captures any viral particles before they are released to the air. “There are countless CPAP and BiPAP machines idling around the world while all resources go towards invasive ventilation,” explains Dr. Azad Mashari, Anesthesiologist at UHN’s Peter Munk Cardiac Centre. “Our mask aims to put these machines back into the clinician’s toolkit. By eliminating air leaks, we can improve patient safety and significantly reduce the risk of contracting COVID-19 for health-care workers and other patients.” Drs. Loubani, Mashari and Benjamin Thomson, Nephrologist at Mackenzie Health, were part of a clinical research team that worked with engineers from GDLS-Canada to develop the device within six days. “GDLS-Canada responded quickly to the urgent need to support those on the COVID-19 healthcare frontlines during this global health emergency,” says Doug Wilson-Hodge, GDLS-Canada’s Manager of Communications, Community and Government Relations. “The innovative design was very much a collaborative effort between all

parties to contribute solutions to the COVID-19 pandemic.” The initial clinical trial will test the device with up to 50 patients at LHSC’s Victoria Hospital and University Hospital with plans to expand to UHN. In addition to patients with COVID-19, participants will include those with asthma, chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The research team anticipates other hospitals in Ontario and across Canada will join the study to create a multi-centre clinical trial. The device will be used in emergency departments and has potential to be used in intensive care units, remote nursing stations and during pre-hospital transport. It has also been designed for easy production in resource-strained locations. “This problem affects everyone and it’s critical that we all do what we can to help,” adds Dr. Loubani. “We hope it will help not only those in urban centres like Toronto and London, but people in remote communities around the world.” The trial is being supported with funding from Glia, an organization internationally recognized for producing medical supplies that are easily accessible and can be manufactured in H low-resource settings. ■

Robert DeLaet works in Communications and External Relations, Lawson Health Research Institute. 18 HOSPITAL NEWS JUNE 2020

The genome Continued from page 17

Global Alliance for Genomics and Health standards will govern the responsible and secure sharing of all data. We are already seeing the results of this coordinated open approach, with improvements in virus tracking, as well as progress in development of antivirals and vaccines. Genomics has also provided us with a glimpse of where this virus may have come from. But we must not lose sight of the bigger picture. As SARS-CoV-2 circulates among humans – one of the most abundant species on earth – we risk infecting other species. This may both threaten their health and create new viral reservoirs that may spill over back into humans. We urgently need genomic information on animals in Canada. Genomics can also help in surveillance, in anticipation of further waves of COVID-19. Establishing a national capacity now, while optimizing provincial coordination, means we can build sustainability by continuing to sequence in real time as more cases arise. Maintaining this capacity and infrastructure, and carrying on with basic research, will allow us to be less reactive in the future. We simply cannot afford to get complacent in that period before the next pandemic strikes. Our future responses will be more rapid and effective if we can pivot nimbly to a new virus within an established framework, and with proven tools and networks. What has heartened me and kept me going is the incredible openness and collaboration that I have witnessed at Sunnybrook Health Sciences, in our Ontario institutions, and across Canada’s research, public health, and health care ecosystem. Thank you to all the nurses and physicians for your clinical care of patients, to Infection Prevention and Control practitioners for keeping us safe, and to technicians, students, and post-docs at the bench for keeping us smart. I have never seen people rally together like this. We must carry forward this new reality so that we are resilient and prepared in the H future. ■ www.hospitalnews.com

EVIDENCE MATTERS

Weeding through new evidence on

medical cannabis By Colleen Donder hile the legalization of cannabis in Canada has made the drug more accessible, there are still important pieces of information that people should consider when trying cannabis for medical purposes. Like alcohol and tobacco, cannabis comes with its own risks, and it may not be the answer for all medical problems. CADTH – an independent agency that finds, assesses, and summarizes the research on drugs and medical devices – wrote a Hospital News article in January 2018 on the medical cannabis evidence available at that time. Since then, CADTH has continued to look for emerging evidence on medical cannabis for treating symptoms of various medical conditions.

nabis for patients with dementia. More research is needed to be sure of the potential benefits and to take a closer look at the potential harms. We also need more information on dementia patients who are under age 65 and information on how medical cannabis compares with other common treatments used for this population.

DOES MEDICAL CANNABIS WORK TO TREAT CHRONIC PAIN?

CADTH was asked to review the evidence on medical cannabis for the treatment of chronic pain. We found evidence on pain related to fibromyalgia, musculoskeletal pain, Crohn disease, and multiple sclerosis; however, the findings from this research weren’t clear, so we don’t know if medical cannabis can reduce pain for these patients. We did find some evidence to suggest that, for people with neuropathic pain, cannabis may have some benefit, but the benefits need to be weighed against the harms. We didn’t find any evidence for any other pain conditions. We also didn’t find any evidence on the clinical effectiveness of medical cannabis compared with other treatments for pain. As is often the case, more research is needed to know where medical cannabis fits as a treatment option for people with different types of chronic pain.

IS MEDICAL CANNABIS SAFE TO USE WITH OTHER MEDICATIONS?

DOES MEDICAL CANNABIS WORK FOR SYMPTOM CONTROL IN PALLIATIVE CARE PATIENTS?

There are many different reasons a patient may be receiving palliative care, but CADTH found evidence on the palliative use of medical cannabis only for patients with HIV, terminal cancer, and Alzheimer disease. There was not a lot of evidence and what we did find was of low or very low quality. Therefore, it’s uncertain what role medical cannabis may play for symptom control in palliative care patients. The low or very low-quality studies that we did find suggest that for those with HIV, medical cannabis might improve appetite and weight gain, but it also increases the risk of psychiatric side effects. For patients with cancer, dronabinol (a synthetic version of cannabis that isn’t available in Canada) might not work as well as the drug megestrol for improving appetite, weight gain, and health-related

quality of life, and more people may stop taking dronabinol because of side effects. Lastly, for Alzheimer disease, dronabinol might help with weight gain and mental health symptoms. More research is needed on different palliative care populations and on medical cannabis products available in Canada, to better understand if medical cannabis has a role in palliative care in this country.

DOES MEDICAL CANNABIS WORK FOR SYMPTOM CONTROL IN PATIENTS WITH DEMENTIA?

The evidence suggests that medical cannabis may help treat agitation, disinhibition, aberrant behavior, nocturnal behavior disorders, as well as aberrant vocalization and resisting care in patients with dementia. It may also improve rigidity and cognitive scores. However, the available evidence is of low quality; therefore, there’s uncertainty about the role of medical can-

Unfortunately, there’s not a lot of evidence to help answer this question. We found low quality evidence that oral cannabidiol (a cannabis extract not available in Canada) increases blood levels of epilepsy medications such as clobazam, eslicarbazepine, topiramate, zonisamide, and rufinamide, but we don’t know what those increased blood levels mean for patients. More research into how medical cannabis interacts with other medications will help us better understand how to use medical cannabis safely. These are just a few of the evidence reviews CADTH has been asked to do on topics related to medical cannabis. You can find all of our related evidence at www.cadth.ca/cannabis. But CADTH is just one organization of many working to answer your questions about the medical use of cannabis. The Canadian Centre on Substance Use and Addiction (CCSA) has information on cannabis research, including the Clearing the Smoke on Cannabis series, and Health Canada has many resources on the medical use of cannabis If you’d like to learn more about CADTH and our evidence reviews on this and other topics, please visit www.cadth.ca, follow us on Twitter at @CADTH_ACMTS, or speak to the CADTH Liaison Officer in your H region. ■

Colleen Donder is a knowledge mobilization officer at CADTH. 20 HOSPITAL NEWS JUNE 2020

www.hospitalnews.com

15th Annual Hospital News!

NURSING HERO AWARDS Happy Nursing Week to all Nursing Heroes!

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ers during this challenging time!

Hospital News and its Advertising Supporters salute all of Canadaâ&#x20AC;&#x2122;s healthcare provid

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SAFE MEDICATION

Communication is key to medication safety By Amy Botross, Ereny Botross, and Certina Ho ommunication is an integral part of the numerous patient interactions that pharmacists have in a typical workday. It is essential at prescription drop-off where critical medical/medication information can be clarified with the patient and potential errors can be intercepted early on. It is also important during patient counselling when the prescription is being picked up, the step that serves as the final opportunity for pharmacy professionals and/or staff members to catch any errors before the medication leaves the pharmacy. Thus, knowing the right questions to ask and how to ask them is crucial to ensure those interactions are efficient, effective, and safe. Although this might seem straightforward, a busy work environment can make it easy to miss simple, yet, key communication points. It can be quite tempting to shorten the patient-pharmacist interactions by simply asking several “yes/no” questions, which may pose significant threats to patient/medication safety. In this article, we will be highlighting some important considerations for patient-pharmacist interactions and discuss why it is essential to go beyond a simple “yes/no” dialogue.

CONFIRMING PATIENT IDENTITY

Any patient-pharmacist interaction will typically begin with a confirmation of the patient identity. It has become common practice in a pharmacy that pharmacy professionals and/or staff members will use two unique patient identifiers (e.g. name and date of birth) to confirm patient identity, thus ensuring the right medication is going to the right patient. It is particularly important to have patients “offer” the information, rather than just responding with an affirmative (or negative) answer. This is because there are mul-

Considerations

Don’ts

Do’s

Confirming Patient Identity

Are you Mr. Paul Smith?

What is your name?

Is your date of bi rth mm/ddlyy?

What is your date of birth?

Confirming Medication Indication

Are you using metformin for diabetes?

What are you using metformin for? Why did your doctor prescribe you metformin? (Note: Metformin can be used for diabetes, or polycystic ovary syndrome, etc.)

Are you using oral contraceptives for birth control?

What are you using oral contraceptives for? Why did your doctor prescribe you oral contraceptives? (Note: Oral contraceptives can be used for birth control, menstrual cycle control, or acne, etc.)

Do you have any questions or concerns?

What are your questions or concerns about what we just discussed?

Opportunity for Questions

Do you need any further clarification? tiple factors that may lead to miscommunication, for instance, language barriers, hearing problems, confusion or altered state of awareness, and the possibility that some identifiers (e.g. patient names) may sound alike (particularly among family members). In extreme cases, such miscommunication may lead to incorrect or potentially high-alert medications dispensed to the wrong patient. Therefore, by asking patients open-ended questions, patients can then verbally share their information, and pharmacists will, thereby, accurately confirm patient identity and ensure that the right medication is given to the right patient.

CONFIRMING MEDICATION INDICATION

It is equally important to inquire patients about the indication of their prescriptions/medications to ensure safe and effective medication use. Pharmacists should avoid making assumptions about the indication, no matter how “obvious” it might be. Therefore, instead of asking patients if they are using a medication for a specific purpose, pharmacists should ask what the purpose of the medica-

tion is. Again, expecting the patient to give a simple affirmative (or negative) response can be misleading. Being open-minded and inquiring patients about the indication of their prescriptions/medications can be helpful in two ways. First, it helps pharmacists gauge patients’ understanding of their medications or medical conditions. Second, some medications may have multiple indications, and some may be prescribed for an off-label use. Therefore, reminding or inviting patients to “offer” their pharmacists the indication of their prescribed medications will be extremely helpful for pharmacists to assess the appropriateness and accuracy of the medications and their associated dosing instructions, etc.

Your Medications” (https://www. ismp-canada.org/medrec/5questions. htm) is a framework that patients can use to ask questions to their healthcare providers and learn more about their medications. Prompting patients to share their thoughts and concerns, instead of simply asking if they have any further questions is more inviting. The latter questioning style may discourage patients from sharing their views with the assumption that pharmacists are rushing to conclude the conversation, while the former is more engaging, as it encourages questions by implying that pharmacists are expecting questions, ready to answer them, and are willing to address any of the patients’ medication concerns.

OPPORTUNITY FOR QUESTIONS

CONCLUSION

Towards the end of a patient-pharmacist conversation, checking in with patients to see if they have any further questions is another common practice. Since the patient is a part of and a key member of the circle of care, they should always be encouraged to ask questions to their healthcare providers. The “5 Questions to Ask About

In conclusion, shortcuts are appealing to save time (especially during a busy workday), but can be risky in critical tasks such as patient-provider interactions. Effective communication is essential for patient/medication safety. Pharmacists should do their due diligence to ask the appropriate questions to minimize chances of miscommuniH cation and reduce the risk of errors. ■

Amy Botross and Ereny Botross are PharmD Students at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and Leslie Dan Faculty of Pharmacy, University of Toronto.] 22 HOSPITAL NEWS JUNE 2020

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FROM THE CEO’S DESK

Advancing patient and family centered care in the COVID-19 era By Dr. Joshua Tepper n the last 90 days hospitals have been faced with an inordinate volume of difficult decisions. One of the hardest has been dramatically restricting visitors including family members and caregivers. It was a decision made to help reduce the risk of COVID-19 being brought into the hospital and to preserve scarce personal protective equipment. While the decision was made for good reasons, it can feel like we are stepping backwards on what has been steady progress on building a patient and family-centered healthcare system, including national campaigns to create family present policies in hospitals. It is also a decision that feels counter to research by the Canadian Foundation for Healthcare Improvement which shows that family involvement increases staff satisfaction and creates a sense of allyship and partnership that contributes to improved relationships between the healthcare team and the patient. Both physicians and caregiver advocates like Julie Drury have highlighted the impact that the absence of family and caregivers during the pandemic has had on patients and the delivery of clinical care in both in-patient and ambulatory settings. Patients have greater loneliness and isolation. They may lose someone who can advocate for their needs or

help manage cultural and language barriers. Providers lose key sources of information and an extra set of experienced hands who are used to providing care for that patient. It is also hard to give and receive difficult information other than face-to-face. There have been many calls for the removal of the visitor restrictions, and some places like British Columbia have revised their policies. However, it is realistic to think that for the foreseeable future some level of restriction on visitors is going to continue. It is also understandable that some families and caregivers may be reluctant or unable to visit during this time regardless of hospital policy. The opportunity becomes how to continue our advancement of patient and family caregiver care rather than stepping back during this difficult time. There are several ways to do so. Current policies tend to be broad in their application while clinical care can be nuanced. There may be a need for more tailored approaches for certain patients or clinical areas like labour and delivery. There is also a role for virtual communication. North York General Hospital in Ontario, like other hospitals, now uses iPads and other tablet technology to facilitate virtual visits – timing of visits can even be arranged online. This is only part of the solution

and there are limitations including technical proficiency of patients, families or staff; the staff time required to set up and run these visits; and privacy concerns. There are also simply some things that cannot be easily communicated or accomplished virtually. Another digital solution is portals to access a patient’s personal health information. Early in the pandemic North York General Hospital implemented MyChart which is a portal used by patients and, if they wish, their families and caregivers. Depending on implementation these portals can also facilitate two-way digital communication between the family and the care team. Some solutions for the loss of family visitors are not as clear. For example, one of the greatest losses is the presence of families during bedside rounds. Bedside rounds for care and teaching are embedded deeply into the culture and processes of a hospital. In recent years the engagement of families and caregivers in rounds has been recognized as beneficial. Families make significant effort to be present for morning rounds for the chance to learn, facilitate shared decision making, raise key issues and help with discharge care planning. It would not be unusual to see several people waiting with the patient for the care team to arrive. The presence of families in ambulatory care settings like the Emergency De-

partment is also missed. Solutions will require rethinking of processes, technology (including ‘old school’ phones), roles of health care providers and potentially even compensation. We also need to think about vulnerable groups and their specific needs. For example, those with communication and cognitive challenges or advanced physical decline may need different approaches. We also need to consider those with mental health issues; who are unfamiliar with our health care system such as new Canadians; and those who have had negative experiences with healthcare in the past. Looking beyond visitor policies, much is being written about how the pandemic is a chance to reimagine our healthcare system especially as we look towards defining our ‘new normal’. Families and caregivers must be part of this re-design process. They should help us co-design our new normal including how to appropriately and safely involve families and caregivers. Their voices and involvement matter H for ensuring exceptional care.■

Dr. Joshua Tepper is President and CEO, North York General Hospital.

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JUNE 2020 HOSPITAL NEWS 23

LONG-TERM CARE NEWS

How ROSA the robot will help

isolated seniors and support aging in place By Mary Gooderham ocial isolation presents practical challenges for many older adults living at home, especially those who are cut off from the helping hands of others under the recent COVID-19 measures. Stairs can be a big problem. There’s the strain of carrying everyday items like groceries or laundry baskets up and down even short flights of steps – and the risk of falling. A Toronto startup has developed a service robot that automatically shuttles household items between floors, virtually hands-free. “We have an automated solution that helps seniors to age in place, and it’s timely given the need for us all to remain physically distant these days,” says Dr. Frank Naccarato, president of Quantum Robotic Systems Inc. (QRS). Dr. Naccarato, an aerospace engineer who specializes in robotics, was originally inspired to develop the stair-assist technology after his aging parents had trouble managing in their two-story home and had to move to a long-term care facility. His first effort, called Step-E, has a patented motorized mechanism that allows it to shuttle items up and down stairs, adjusting to each step it encounters while keeping the load level. He next developed a larger version for commercial applications called Doll-E that can handle up to 500 pounds. It does much the same job as the “handtrucks” used by movers, delivery people and heavy industry but can go up and down stairs under its own power, saving time and labour. There’s lots of interest in Doll-E in the moving business, Dr. Naccarato says, however that industry has been hampered by COVID-19 regulations and economic difficulties. With the pandemic making it necessary for seniors to shelter in place, he pivoted to refining the technology for the home. Enter the Robotic Stair-climbing Assistant, or ROSA, a compact cart that

Dr. Frank Naccarato with Rosa, a compact cart that carries items up to 100 pounds on stairs. carries items up to 100 pounds on stairs. Dr. Naccarato developed ROSA in collaboration with George Brown College’s School of Mechanical Engineering Technologies, assisted by Strategic Investment Program (SIP) Accelerator funding from AGE-WELL, Canada’s Technology and Aging Network. Dr. Naccarato says ROSA could not have become a reality without a team of faculty and students at George Brown, led by Professor James McIntyre, which perfected it under the COVID-19 lockdown conditions. Dr. Naccarato delivered parts to students’ homes so they could continue their research. “It was challenging, but we did it,” he says. AGE-WELL’s support “has been invaluable,” Dr. Naccarato says, helping finance the development of ROSA while suggesting other funding, marketing and promotional opportunities. At an AGE-WELL workshop, he presented ROSA to a group of older

adults and caregivers who provided valuable feedback on issues such as types of control mechanisms suitable for older adults. His goal is to make ROSA ultra-easy to use. He envisions it as a “discrete appliance”, about the size of a piece of carry-on luggage, tucked away on its own charging station when not in use, much like the storage of those “robot” vacuums becoming ubiquitous today. Existing solutions for steps such as stair-lifts can be extremely expensive, he says, and they aren’t meant to carry objects. By autumn, Dr. Naccarato plans to conduct tests in people’s homes with a ROSA that has climb-and-wait capability, controlled wirelessly. The device could be on the market soon after. Future versions will be voice controlled. They will be able to transport objects from room to room, and to work outdoors, for example from the driveway to the porch.

The technology could also be used for “touchless” curb-to-door deliveries by companies like Amazon, he says, or to shuttle items to people who are sick or recovering from illness, say on different floors within the house. ROSA is also “expandable” and could be fitted with a camera to become a “telepresence” platform to check on people in isolation, says Dr. Naccarato. He has also designed a prototype stair-climbing wheelchair, called the Wheel-E. It’s a portable alternative to fixed ramps and installed stair-lifts, explains Dr. Naccarato, who is driven by a strong desire to solve problems. “Problem-solvers are motivated by that rare feeling of seeing their solution – which previously existed only in their imagination – become something genuinely useful in the real world,” he says. “If I not only solve the problem but also do it in a creative and original H way, it’s all the more gratifying.” ■

Mary Gooderham is an Ottawa-based freelance writer. AGE-WELL is a federally-funded Network of Centres of Excellence. The pan-Canadian network brings together researchers, older adults, caregivers, partner organizations and future leaders to accelerate the delivery of technology-based solutions for healthy aging. For more information, visit http://agewell-nce.ca/ 24 HOSPITAL NEWS JUNE 2020

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LONG-TERM CARE NEWS

Home care volunteers ramp up for COVID-19 relief By Isabel Terrell s home care organizations continue to provide critical services to help keep people safe at home and out of hospital, volunteers at VHA Home HealthCare (VHA) are helping out in new ways amid the COVID-19 pandemic. The organizationâ&#x20AC;&#x2122;s regular volunteer activities serve some of Torontoâ&#x20AC;&#x2122;s most vulnerable communities through hoarding support services, child and family services and at-home ESL tutoring programs. When physical distancing measures came into effect in March and these programs were temporarily halted, the organizationâ&#x20AC;&#x2122;s volunteers were in search of other ways to make a positive impact.

With so many areas of health and community care in need of support, VHA quickly identified a variety of areas that volunteers could take on. Some volunteers are gathering grocery essentials for clients in need. â&#x20AC;&#x153;In a time where the world feels so lonely, it is so rewarding to reach out to someone who could use a little extra help,â&#x20AC;? says Heather Chagnon, volunteer. Chagnon volunteers in Hoarding Support Services and recently started dropping off groceries when a client of VHAâ&#x20AC;&#x2122;s Child and Family Services program reached out. Her newborn child was allergic to all the baby formula she had and she wasnâ&#x20AC;&#x2122;t sure what to do. Chagnon stepped in to find the right formula and deliver it, keeping the mother and baby safe at home.

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cery delivery program were donated through the United Way Greater Toronto Local Love Fund, an emergency fund for COVID-19, allowing this essential assistance to continue and grow. Chagnon also calls clients who live alone each week to check on them and help them feel connected during this time when social isolation can be challenging for so many.

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LONG-TERM CARE NEWS

VHA Home HealthCare is a is a not-for-profit, charitable organization that offers 24/7 health care and support services across seven Local Health Integration Networks across Ontario. Its team of professionals includes nurses, occupational therapists, physiotherapists, personal support workers, home support workers, cleaners, social workers, dietitians, and speech-language pathologists. The organization is also a founding member agency of the United Way Greater Toronto. Some volunteers are also involved in delivering Personal Protective Equipment (PPE) for front line staff – an initiative that helps hundreds of Toronto-based health care workers continue to provide essential care to vulnerable clients each week. “I’ll look back on this time and know that I did the best that I could,” says Clara Moroch, a Child and Family Services volunteer alum-

ni who is once again working with VHA to deliver PPE. Clara is also hand-sewing cloth masks to contribute to the organization’s PPE drive and is keen to help during this crisis. “If I can help out in any way, I think doing anything is better than nothing.” These new volunteer initiatives don’t only help vulnerable clients. They also give volunteers, many of whom are experiencing sudden unemployment because of COVID-19, a fulfilling way to spend their time and stay connected. Pre-pandemic, volunteers already meant the difference between isolation and social and community connection and improved mental health, says Dawn Ashford, VHA’s Volunteer Coordinator. “Now, they bring their passion and dedication to the forefront of the fight against COVID-19 as they nimbly adapt to changing needs in our H community.” ■

Isabel Terrell is a Communications Specialist at VHA Home HealthCare.

Care after hospitalization

about where to turn, how to cope and where to get help. can be an overwhelming process. Our goal is to ensure that feel most comfortable – home.

Support is just a phone call away.

1.877.289.3997 clientservice@bayshore.ca

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JUNE 2020 HOSPITAL NEWS 27

NEWS

A patient’s experience at the ED during COVID-19 By Natalie Leung s the COVID-19 pandemic continues, many people may have fears about seeking medical attention at hospitals – that they might expose themselves to the virus, or be an unnecessary burden on the health system. Paravaneh Laraya learned those fears aren’t necessary. Earlier this month, Laraya got up at night, slipped and fell. The next morning, she felt pain in her arm and wasn’t sure if she needed any additional medical attention. She called her daughter, Dr. Nadine Laraya, a local family physician and the Community Family Medicine Liaison at St. Joseph’s Health Centre, who told her to visit the Emergency Department (ED). “It’s a unique situation that I’m in, being on both the care side and the patient side,” says Dr. Laraya. “But when I realized that my mom had fallen and

needed medical attention, there was no doubt in my mind that emergency rooms were safe for her to use.” Although she had some concerns about seeking care at a hospital during the pandemic, Laraya took her daughter’s advice and went to St. Joseph’s ED. “When I was heading to the hospital, COVID-19 came to mind. But when I arrived, I saw that it was a good setup – there was a lot of room in the waiting area and people were able to stay far apart from one another,” says Laraya. “It made me feel safe.” When patients enter the EDs at St. Joseph’s and St. Michael’s Hospital, they are screened for signs, symptoms and contact with COVID-19. They go through the standard triage to ensure they are assessed in the safest and most appropriate area. “Some patients are waiting too long to seek urgent care which is concern-

ing because it can potentially lead to further issues,” says Sonya Pak, Senior Clinical Director, Emergency and Medicine at St. Joseph’s. “If you require care, you should come to the hospital and not delay – we’ve done a lot of work to make sure everyone is safe and gets the care they need.” Proper precautions, such as hand hygiene stations and physical distancing measures, are in place throughout our hospitals. In addition, both the St. Michael’s and St. Joseph’s COVID-19 Assessment Centres are located outside the main hospital buildings. For those who are unsure if they need to go their nearest ED, Dr. Laraya suggests reaching out to a family doctor or calling Telehealth Ontario. “Most family doctor offices are still operating. They can provide a bit more guidance on whether or not a visit to the ED is something that is required.”

Dr. Nadine Laraya holds a photo of her mother, Paravaneh Laraya. After examination, Dr. Laraya’s mother found out she had broken her arm during her fall. She now has several follow-up appointments scheduled at the Health Centre’s Fracture and Orthopaedic Clinic. She hopes her story will encourage other patients to seek medical help when they need it. “My experience was pleasant, fast and efficient,” she says. “I was glad I went to St. Joseph’s because I received H really good care.” ■

Natalie Leung is a communications adviser at Unity Health Toronto.

Social distancing doesn’t mean social isolation By Michael Oreskovich alancing patients’ emotional needs and their safety has never been more challenging than during the COVID-19 crisis. Although social distancing is essential for preventing the spread of infection, it also has the potential to make patients feel alone and isolated at a vulnerable time. By rethinking how it delivers programs and using technology in innovative ways, Runnymede Healthcare Centre ensures patients are safe during their hospital stay, without sacrificing the patient experience. Starting in February, measures were in place at the hospital to protect patients and staff from the spread of COVID-19, but these escalated dramatically when the pandemic was declared. All visiting was immediately

suspended and large group activities were put to a stop. The measures were essential to take, but they removed key sources of support for patients. “The limits on patients’ social interactions are necessary, but they could also negatively impact their quality of life or even affect their therapy,” said Sarah King, Runnymede’s director of client relations and community engagement. “We recognized that action was needed to maintain patients’ connections with others – it was a priority for us to ensure they weren’t isolated in their rooms.” One way Runnymede’s activation team responded was by making tablet devices available to patients, enabling face-to-face video chats with loved ones while visiting restrictions are in effect. In addition to helping patients stay connected, they also alleviate anxieties felt by families and loved

ones who desperately want to provide their support. “The devices are in non-stop use for video chats,” said King. “To meet the high demand, we had to double the number of tablets we have at the hospital ever since we suspended visiting.” Since the devices are handled by multiple patients over the course of a day, they are cleaned between each use. The devices are kept in protective enclosures that are designed to withstand regular cleaning with disinfectants. With safety modifications in place, the hospital continues to run its activation programs to the fullest extent possible. Sessions during the pandemic occur in smaller settings, with team members ensuring participants are kept a safe distance apart. Celebrations that normally would have been hospital-wide have been converted to floorbased events involving smaller groups.

“In some cases, we incorporate the tablet devices into our activation programming,” said King. “For example, some patients are enjoying virtual tours in place of our regular out trips; others are taking advantage of streaming yoga classes; and those who usually attend our religious gatherings can continue to have their spiritual needs met with online church services.” Patient safety has never been in sharper focus at Runnymede than during the COVID-19 crisis, but the hospital is ensuring it upholds its commitment to an outstanding patient experience. “At a time like this, helping patients connect with loved ones and others in the hospital is crucial for preventing them from feeling disengaged or slipping into depression,” said King. “Through the actions we’ve taken, we’re showing that social distancing H doesn’t mean social isolation.” ■

Michael Oreskovich is a communications specialist at Runnymede Healthcare Centre. 28 HOSPITAL NEWS JUNE 2020

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NEWS

Using existing studies

to generate new understandings of COVID-19 By Ana Gajic xisting research may hold the key to treating and preventing COVID-19, suggests the work of a St. Michael’s Hospital research team. The Knowledge Translation (KT) Program of the Li Ka Shing Knowledge Institute has been working with organizations such as the Public Health Agency of Canada, Health Canada, Canadian Frailty Network, and the World Health Organization (WHO) to conduct rapid reviews of literature that could be helpful in efforts to understand and combat the virus. These collaborations are through two Canadian Institutes of Health Research initiatives, the Drug Safety and Effectiveness Network Methods and Applications Group for Indirect Comparisons and the Strategy for Patient-Oriented Research Evidence Alliance. Rapid reviews are analyses completed quickly of all existing studies around one topic area – they capture a global picture of knowledge and categorize it all in one study. “With a rapid review, we can summarize the evidence on what worked previously for coronaviruses such as SARS and MERS,” says Dr. Andrea Tricco, Director and Scientist of the KT Program’s Knowledge Synthesis Team. “We can also quickly analyze literature that is coming out now from all around the world – such as from Italy, China, Spain and Iran.” The Knowledge Synthesis Team at St. Michael’s consists of 30 highly trained individuals who help with the coordination, screening, data abstraction and verification of results. They collaborate closely with clinicians at St. Michael’s to ensure their results are relevant to patient care. “By summarizing the results of multiple studies, we have more confidence in our conclusions and more statistical power to identify differences between treatments or tests,” Dr. Tricco says. So far the team has worked on one review to look at medications that could be used as countermeasures to COVID-19. Their analysis of 54 studies found that a medication that has

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commonly been studied in coronaviruses – ribavirin – has not had conclusive evidence to suggest its efficacy, and may cause negative outcomes. They are currently working with Health Canada to update this review to examine treatments for coronavirus. Another set of rapid reviews conducted by the team in partnership with the WHO looked at preventing respiratory illness in adults aged 60 and older living in long-term care. These rapid reviews (found here and here) identified limited evidence to provide guid-

ance to the WHO based on the literature, which underscored that this was an underserved area. The team is now working on updating this rapid review for the Canadian Frailty Network and are working closely with Health Canada on additional potential reviews. “The most interesting part of these reviews is that initially there wasn’t a lot of evidence and now we’re seeing new studies publishing daily,” Dr. Tricco says. “This is a rapidly changing area – things change by the day and sometimes the hour.”

To that end, the KT team is working to make all their published reviews ‘living reviews’ that will be updated at least every few days. They’re ensuring that all materials are publicly available and accessible in plain-language one-page summaries. “We hope that our findings will help provide evidence to researchers, health care providers and policy makers on COVID-19 here in Canada, as well as globally, that can be used in H their decision-making.” ■

Ana Gajic is a senior communications adviser at Unity Health Toronto.

Climate does not impact the spread of COVID-19 By Peter Jüni he COVID curve has bent – the worst is probably behind us. But in many ways, the period just ahead could be a greater test for Canadian hospitals than when we were in full crisis mode. Packed crowds in Toronto’s Trinity Bellwoods Park on the first warm weekend day are an ominous sign. A second wave of COVID seems virtually guaranteed, and I wonder how many Canadians will be willing to take a step back into social isolation once again? That’s a looming problem for our hospitals, now that we are getting back to elective surgeries and business as usual. Until recently, many of us have unconsciously or consciously hoped that summer would kill off the virus, giving hospitals time to regroup and plan for increased capacity in the Fall. Unfortunately, we have learned that climate makes no difference to the spread of COVID. Working with fellow epidemiologists at the Dalla Lana School of Public Health, I analyzed the outbreak across the world for a one-week period in March, and found that countries experiencing hot weather, such as Singapore, were no

better off for it than cold climates, such as Canada. We found the only factor that worked was physical distancing. That’s why it makes me nervous that in Ontario, where most stores are back in business and day camps will run this summer, our dedication to distance is about to be tested.

WHAT DOES THIS MEAN FOR HOSPITALS?

Until there’s a vaccine, we will have to manage our patient loads without the crutch of a society in slowdown. But we’ll need to keep vigilant to protect our most vulnerable patients, such as those undergoing transplants and cancer treatment. With increasing opportunities to gather, there will be constant local outbreaks, which will hopefully be contained through local measures. Some hospitals may have more COVID patients than at the height of the crisis. As a result, it will be crucial for hospital leadership to understand where cases are springing up in our communities. I suggest you make it your business to ensure appropriate contact tracing and containment is happening in your area. If not, you’ll be dealing with

the ramifications coming through your doors. And it’s not just about preparing for local surges. As a hospital leader, are you prepared to use your platform to call for containment when warranted? Until now, decisions have been made for entire provinces. But going forward, measures at the province level will be unlikely to ensure the pandemic stays in check while keeping the economy afloat – rather we’ll need swift, granular reactions at the community level to close down day camps or businesses temporarily. Local leaders such as mayors, school boards, and local medical officers have the power to make these decisions. But they may need support if these decisions are uncomfortable. Hospital leaders can and should provide this support. At times you may also need to speak out on your own. I believe hospital leaders could be the trusted experts to make a big difference in the way communities respond to their outbreaks. This will involve not just stepping up and stating (sometimes) unpopular truths. It also means battling red tape to collaborate with researchers on randomized trials to test treatments and on epidemiological and fundamental research studies H to help understand the virus. ■

Peter Jüni is a professor of epidemiology at the Dalla Lana School of Public Health’s Institute for Health Policy, Management and Evaluation (IHPME). JUNE 2020 HOSPITAL NEWS 29

NEWS

St. Michael’s could be the ‘catalyst’ for global collaboration on COVID-19 clinical research By Ana Gajic clinical trial set up to enable a rapid response to future pandemics now has even broader reach as it has aligned with a global research response to understand treatments for COVID-19. Led by St. Michael’s Hospital’s Dr. John Marshall, scientist at the Keenan Research Centre for Biomedical Science and critical care doctor, the Canadian arm of the study, REMAP-CAP, has aligned its goals with a worldwide clinical trial led by the World Health Organization (WHO), called SOLIDARITY. The SOLIDARITY Trial is examining four potential treatments for COVID-19: a drug previously tested for Ebola, MERS and SARS (Remdesivir); a treatment used for HIV (Lopinavir/Ritonavir); a treatment used currently for Multiple Sclerosis

(Interferon beta-1a) and medications used for malaria and rheumatology conditions (chloroquine and hydroxychloroquine respectively). While REMAP-CAP is studying some of the same interventions as the WHO’s SOLIDARITY, it is also studying interventions relevant to the most critically ill patients around the world. REMAP-CAP, which stands for Randomised, Embedded, Multifactorial, Adaptive Platform for Community Acquired Pneumonia, is an adaptive trial. Instead of traditional clinical trials that test one treatment at a time, adaptive trials allow scientists to test multiple treatments simultaneously in the same patient groups and randomize patients to receive the treatments that seem to be faring the best, giving them the best opportunity to be treated. “We set up REMAP-CAP precisely to prepare us for the next pandemic,”

says Dr. Marshall. “And as COVID-19 has swept across the world, we have looked to position our trial to support the global effort.” REMAP-CAP is recruiting patients on four continents. Its Canadian arm is led by St. Michael’s, in close collaboration and coordination with SOLIDARITY/ CATCO – led by Dr. Srinivas Murthy, an infectious diseases and critical care physician at BC Children’s Hospital and a clinical associate professor in the University of British Columbia’s department of pediatrics in Vancouver. The trial is looking to expand to 80 Canadian ICUs, as the more centres and patients are enrolled, the faster the generation of evidence will be. “This scale of collaboration is unprecedented,” says Dr. Marshall. As a critical care doctor, Dr. Marshall has seen pandemics – from SARS to H1N1. This level of dedication to research is unique to COVID-19.

“This time around there is a collective understanding that good research is what’s going to help our patients through this pandemic,” Dr. Marshall says. As Canada’s premier critical care hospital, Dr. Marshall sees St. Michael’s as a catalyst in the Canadian arm of this global work. In his work as a co-lead of the WHO Clinical Characterization and Management Working Group, Dr. Marshall works with global peers to make sure centres are tracking similar outcomes so that the WHO will be able to compare research across centres. “This is something that’s very special to critical care,” he sayst. “There’s a sense of collegiality that doesn’t always exist in other fields. There was an appetite to collaborate during H1N1 – now, with H COVID-19, we’re delivering on it.” ■ Ana Gajic is a senior communications adviser at Unity Health Toronto.

Research helping patients with COVID-19 By Carrie Stefanson hirty-two year old Zee Rahiman is alive today thanks to exceptional health care and madein-BC research that is benefitting patients with COVID-19. The otherwise healthy Vancouver resident hit the wall in late March. “I was coughing and vomiting and had a fever. When doctors at Vancouver General Hospital (VGH) put me on a ventilator to breathe, I thought: I might not make it.” Zee is one of 65 people currently enrolled in a clinical study examining the immune-system response of patients with COVID-19. A small team led by Dr. Mypinder Sekhon, an intensive care physician at VGH and Dr. Cheryl Wellington, a Professor in the Department of Pathology and Laboratory Medicine at the University of British Columbia (UBC), are retrieving and processing blood

samples from critically ill COVID-19 patients at Vancouver General and Surrey Memorial Hospital. “In some patients it appears that it may not be the virus itself, but the triggering of an excessive immune response that leads to lung damage,” says Dr. Sekhon. “If we can identify and quell it, patients may improve quickly.” Dr. Sekhon says in Zee Rahiman’s case it was like flipping a switch; personalizing his care in the intensive care unit was associated with a dramatic decrease in the elevated immune system markers in his blood. Using a machine known as a Simoa HD-1 analyzer in Dr. Wellington’s lab at UBC, blood samples that normally take weeks to analyze are processed within 24 hours so ICU physicians have more time to observe a patient’s immune system. For example, elevated inflammatory and immune biomark-

The COVID-19 unit at Vancouver General Hospital. ers may indicate the immune system could overreact and attack the lungs. Dr. Wellington’s lab is the go-to-lab in Canada for blood biomarker information using this type of technology. “There is a bouquet of opportunities here with this very collaborative bench-to-bedside research,” says Dr. Wellington. “We want to take what we learn and help other patients.” The research team is also planning to study the patients long-term, so they can better understand the immune-system response from having COVID-19, including lung and brain

assessments. “We want to keep this success story going and expand and grow this study to benefit people across Canada and internationally,” says Dr. Wellington. “In my whole career as a faculty member, I’ve never seen clinical research move this quickly.” Zee Rahiman is grateful for the speed at which the research team was able to pivot their work and focus on COVID-19. “Just because you’re young and healthy doesn’t mean you can’t get COVID-19. To the research and clinical teams: Thank you for givH ing me a second chance.” ■

Carrie Stefanson is Public Affairs Leader at Vancouver Coastal Health. 30 HOSPITAL NEWS JUNE 2020

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Doctors without Borders: Covid-19 By Colleen Dockerty magine trying to implement physical distancing and wash your hands regularly to stop the spread of COVID-19 while living in overcrowded housing without access to running water, soap or adequate health care. This is the sad reality for millions of vulnerable people living in poverty, in war-torn countries and refugee camps around the world. I am a nurse with Doctors Without Borders. I was recently in Mozambique where we support people living with HIV and sex workers. Through my work, I met a migrant sex worker living with HIV in a small house with 10 other people. She came to the city to earn money to feed her children and pay their school fees. Physical distancing is simply not an option for her. More than two million people live with HIV in Mozambique, many with weakened immune systems. This may

More than two million people live with HIV in Mozambique, many with weakened immune systems. increases the risk of infections and may make them vulnerable to COVID-19. But it’s almost impossible to implement the additional precautions the WHO recommends for people with advanced HIV while living in an overcrowded home. In addition, Mozambique has a weak and poorly-equipped health system, made worse by a recent cyclone. In some clinics I visited, there is not enough running water for health workers to wash their hands to protect themselves and slow the spread of the virus. The potential impact of COVID-19 is even more dire in war-affected regions and refugee camps. At a South Sudanese refugee camp I visited in Ethi-

Small houses like this one often have 10 people living in them, making physical distancing a challenge.

opia, women need to walk to the water pump with plastic jugs, pump water for the day, carry the heavy jugs home and carefully plan what water is for cooking, drinking and washing. They may be faced with the decision of whether this limited water is to cook a meal for their children or wash their hands to prevent the spread of the virus. I also worked in the Rohingya refugee camps in Bangladesh, where almost one million people are living in overcrowded conditions. People are dependent on humanitarian aid for all basic services, food and fuel. Young boys walked barefoot in the mud, carrying heavy bags of food on their shoulders. Large crowds gather to access food – making physical distancing impossible. COVID-19 is likely to spread quickly in overcrowded refugee camps that lack basic hygiene, sanitation and health care. The Government of Bangladesh has confirmed that there is a case of COVID-19 in the Rohingya camp. The UNHCR has described Rohingya refugees among the most at risk globally in this pandemic and has urged international support. Canadians have been responding with kindness and support. People are volunteering to buy groceries and babysit for neighbours, and are applauding essential workers every evening and around the country. This solidarity can extend beyond our borders to the poorest and most vulnerable around the world. The UN is calling for increased funding to fight

coronavirus to protect millions of vulnerable people at risk. The Canadian government has committed foreign aid funding as part of this humanitarian response. Doctors without Borders is scaling up its efforts, with a focus on vulnerable populations. Some may argue that Canada should focus its attention at home. However, the pandemic makes clearer than ever how we are all connected. Viruses have no borders. Canadians – individually and through our government – can and must do more to ensure the poorest and most vulnerable are protected from COVID-19. Countries with fragile health systems and humanitarian organizations need support to prevent its spread, to strengthen infection prevention and control, to triage and manage cases. When a treatment and vaccine are developed, they must be affordable, accessible and available for all. Beyond COVID-19 preparedness and response, resources must not be diverted from existing programs. Essential services must continue – providing shelter, food, clean water, responding to gender-based violence and running life-saving health care that reduces maternal mortality, vaccinates against polio and measles, and prevents HIV and tuberculosis. We as Canadians can and must show solidarity to both help ensure our safety at home, and to relieve suffering H globally. ■

Colleen Dockerty is a Registered Nurse with a Masters of Science in Public Health from the London School and Hygiene and Tropical Medicine. She has worked with Medecins Sans Frontieres in Afghanistan, Bangladesh, Ethiopia, Iraq, Mozambique, South Sudan, Sierra Leone, and Papua New Guinea. www.hospitalnews.com

JUNE 2020 HOSPITAL NEWS 31

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