Hospital News September 2020

Inside: From the CEO’s Desk | Evidence Matters | Safe Medication | Online Education | Long-term Care

September 2020 Edition

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FEATURED

Air ambulance:

Cancel it or keep it coming?

Page 12 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

Rights & Freedoms The year 2020 will surely be remembered as the year of the great pandemic. The year when our front-line workers have risked their health to look after those who are sick with COVID-19. The year when nurses and health-care professionals have had to fight for access to the personal protective equipment they need to stay safe. The year when the shortcomings of our long-term care facilities took so many lives and caused families so much pain.

2020 has delivered many lessons. We’ve learned that the workers who society values the least are some of the workers we have counted on most to get us through these difficult times. This vital lesson sits at the heart of Labour Day. It’s why solidarity matters.

Vigilance is one of the most important weapons in the fight against COVID-19. It’s also the best defence against the attack on rights and freedoms that we’re seeing right now in Ontario. Bills 124, 175, and 195 undermine collective bargaining and other constitutional guarantees that labour has fought so hard to gain. The Ontario Nurses’ Association and our members are protesting these measures.

To be sure, the fight will continue.

In that spirit, let’s make this a Labour Day to remember.

nursesknow.ona.org

Stay safe, stay strong.

Contents September 2020 Edition

IN THIS ISSUE:

Virtual emergency department visits

10

▲ Cover story: Air ambulance: Cancel, or keep it coming?

12

▲ In the lab during a pandemic

8

▲ Video laryngoscopy

COLUMNS Editor’s Note ....................4

16

In brief .............................6 Safe medication ............18 From the CEO’s desk .....30 Evidence matters ...........31 Long-term care .............32

▲ Surgeons use virtual reality to sharpen skills

22

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Special focus: Online education

20

▲ Person-centered dementia care

34

Our post-pandemic

future

By Vanessa MacDonnell, Sophie Thériault and Sridhar Venkatapuram hat will our post-pandemic future look like?

This is a question on the minds of many these days. Indeed, in the weeks and months ahead, politicians, policy experts, academics, businesses, non-profit organizations and the broader public will have to make important choices as we rebuild our lives, societies and the international order.

Around the globe, governments at all levels are developing a range of recovery plans. Some of these plans will tilt toward austerity, tacitly accepting that some people can be left behind. Health care budgets may not see significant cuts, but other crucial public goods and services, such as education, could see their funding slashed.

Alternatively, some governments will spend their way out of the economic downturn. These governments will invest significant funds to support businesses and their populations and build new infrastructure in the hope of stimulating the economy. These investments will take different forms. In Canada, for example, there continues to be pressure to bail out the oil and gas sector and to loosen environmental protection measures. But there are also calls to convert the Canadian Emergency Response Benefit, the $500 weekly payment to people who became unemployed as a result of the pandemic, into a universal basic income program.

In short, whether through cutting back or spending more, governments will be faced with choices. And what COVID-19 has shown us all is that the choices governments make can have immediate life or death impacts.

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It is essential to acknowledge that the pandemic is the outcome of policy choices made by governments and not a natural disaster or an “act of God.” The fingerprints of governments and their choices are everywhere, whether at the international level in the regulation of animal-transmitted disease threats and outbreak reporting, the regulation of international trade and travel, or how quickly and what kind of policies were implemented to contain the virus.

The devastating effects of COVID-19 are equally the result of choices: to tax and spend in ways that benefit some and disadvantage others; to intervene or not intervene in the economy when market forces prevent individuals from meeting basic needs; to view health as the product of a combination of luck and personal choices rather than the result of colliding social, economic and political factors; and to adopt particular foreign policies on international cooperation, including foreign aid.

Defective government policies created the pre-conditions for the pandemic as well as the extent of the devastating outcomes. Choosing austerity as the path forward is just a continuation of bad choices and social injustice.

Cutting back government programs and social common goods are likely to further entrench existing inequalities rather than strengthen the economy or protect us from future pandemics and health shocks. Slashing essential programs like education and incomes supports is more likely to create new vulnerabilities than to remedy old ones.

Continued on page 19

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NEWS

Researchers to study inhaled sedatives as solution to COVID-19 drug shortages Inhaled sedatives could reduce lung inflammation, shorten the duration of ventilation and potentially improve survivalsolution to COVID-19 drug shortages

By Robert DeLaet team from Lawson Health Research Institute are being funded by the Government of Ontario’s COVID-19 Rapid Research Fund to study whether inhaled sedatives can replace those that are delivered intravenously in COVID-19 patients requiring ventilation. The multi-centre clinical trial aims to address a global shortage of intravenous (IV) sedatives while improving patient outcomes.

“When COVID-19 patients develop severe respiratory failure and need to be ventilated, they require sedation.

While IV sedatives are currently used, there is concern about global drug shortages, particularly if there’s a second wave of COVID-19 in the fall,” explains Dr. Marat Slessarev, Scientist at Lawson and Critical Care Physician at London Health Sciences Centre (LHSC). “Even if we have enough ventilators, we won’t be able to ventilate patients without sedatives.”

The clinical trial, being co-led by Dr. Slessarev and Dr. Angela Jerath at Sunnybrook Health Sciences Centre, will study the replacement of IV

A

THIS IS THE LARGEST TRIAL OF ITS KIND. IF INHALED SEDATIVES CAN SHORTEN THE LENGTH OF VENTILATION OR IMPROVE SURVIVAL IN PATIENTS WITH RESPIRATORY FAILURE, THIS COULD CAUSE A PARADIGM SHIFT IN THE WAY WE SEDATE PATIENTS IN INTENSIVE CARE UNITS (ICUS) AROUND THE WORLD

sedatives with inhaled sedatives. Inhaled sedatives, also called volatiles, are widely available due to their use in operating rooms to sedate patients during surgery. While they have not been routinely used to sedate patients needing ventilation, early studies suggest they could be safe and even more effective than IV sedatives.

“Preliminary studies in non-COVID patients with severe respiratory failure suggest that inhaled sedatives can reduce lung inflammation, shorten the duration of ventilation and potentially improve survival. Inhaled sedatives

could therefore reduce the pandemic’s strain on ventilator capacity while improving patient outcomes,” says Dr. Slessarev. “Since these drugs are safe, cheap and readily available, they can easily be used to address IV sedative shortages if found effective.”

The researchers will recruit approximately 800 patients from across Canada and the United States including patients from LHSC. Each patient will be randomized to receive either IV sedatives or inhaled sedatives. Patient outcomes such as survival and length of ventilation will be compared between

the two groups to determine which method of sedation is most effective.

Given many survivors of critical illness experience cognitive impairment for months or even years after an intensive care unit (ICU) stay, the team is also planning a sub-study to assess whether one method of sedation results in better cognitive outcomes after treatment.

In addition to funding from the Government of Ontario, the study is being supported with funding from the Canadian Institutes of Health Research (CIHR), London Health Sciences Foundation and Sunnybrook Health Sciences Centre.

Robert DeLaet is a Consultant, Communications & External Relationsat Lawson Health Research Institute.

“This is the largest trial of its kind.

If inhaled sedatives can shorten the length of ventilation or improve survival in patients with serve respiratory failure, this could cause a paradigm shift in the way we sedate patients in intensive care units (ICUs) around the H world,” notes Dr. Slessarev. ■

FREE

Robert DeLaet is a Consultant, Communications & External Relations at Lawson Health Research Institute.

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SEPTEMBER 2020 HOSPITAL NEWS 5

IN BRIEF

Canadian emergency department visits drop 25% in early weeks of COVID-19 pandemic ew data released today by the Canadian Institute for Health Information (CIHI) shows that emergency department (ED) visits dropped by 25 per cent in March 2020, compared with March 2019. This represents a decrease of 318,000 visits during the period where governments and health systems started implementing measures to control the spread of COVID-19. Findings are based on more than 80 per cent of ED visits in Canada reported to CIHI. Looking specifically at the last week of March, after travel restrictions were

IT’S CLEAR THAT MANY CANADIANS AVOIDED VISITING EMERGENCY DEPARTMENTS IN THE INITIAL WEEKS OF THE PANDEMIC

N

imposed and schools and daycares were closed across much of Canada, there is an even more pronounced change: visits decreased by 49 per cent that week compared with the same

time period in 2019. In some cases, visits per day dropped dramatically.

For example, the number of ED visits on March 31, 2020, was about 50 per cent lower than the number of visits on March 31, 2019 (20,427versus 40,803, respectively).

Looking at CTAS (Canadian Triage Acuity Scale) levels – a severity scale that health professionals use to triage patients in Canada’s EDs – the largest volume reduction in ED visits (March 2020 versus March 2019) was seen in CTAS level 4 (less urgent patients), down 29 per cent across Canada. Even among the most seriously ill or injured

patients – those in CTAS level 1, who require resuscitation – there was a 14 per cent decrease.

“We’ve heard anecdotally that visits to emergency departments for issues other than COVID-19 have significantly decreased during the pandemic,” says Greg Webster, Director, Acute and Ambulatory Care Information Services. “The data released today confirms this. When we compare to last year, it’s clear that many Canadians avoided visiting emergency departments in the initial weeks of the pandemic, which may have had serious H consequences for some patients.” ■

Illicit fentanyl, stimulants detected in majority of overdose deaths in BC N

onprescribed fentanyl and stimulants were the primary contributors to overdose mortality, while few people had prescribed opioids in their systems, according to new toxicology research in CMAJ (Canadian Medical Association Journal).

“With health professional organizations introducing guidelines to reduce prescribing of opioids and other controlled substances, understanding the relative contribution of prescribed substances and illicitly obtained substances to overdose deaths is key to developing effective programs to reduce overdose mortality,” writes Dr. Alexis Crabtree, BC Centre for Disease Control and the University of British Columbia, with coauthors.

The postmortem study looked at deaths from drug overdoses identified by the BC Coroners Service between 2015 and 2017 with one or more illicit drugs. The deaths were linked to the person’s prescription medication his-

[P]RESCRIBING POLICIES ARE INSUFFICIENT TO ADDRESS THE CURRENT OVERDOSE CRISIS IN CANADA AND ADDITIONAL STRATEGIES ARE NEEDED

tory in British Columbia’s PharmaNet database. Of the total 2872 deaths, toxicology results were available for 1789 deaths, in which the majority (85.5 per cent) had 1 or more opioids present. However, only 8.7 per cent of individuals had taken prescribed opioids, and methadone and buprenorphine, used in opioid agonist therapy, were rarely detected in postmortem toxicology.

Of the deaths linked to nonprescribed opioids, fentanyl or fentanyl analogues were found in 79 per cent of cases. Stimulants were found in 71 per cent of deaths, almost all nonprescribed. Of the deaths in which benzodiazepines were detected, 63 per cent had not been prescribed.

6 HOSPITAL NEWS SEPTEMBER 2020

Death rates from illicit drugs increased more than fourfold between 2014 and 2018, which has been attributed to the contamination of the illicit drug supply. Over the past 5 years, British Columbia has had the highest rates of deaths from illicit drug use in Canada. “[P]rescribing policies are insufficient to address the current overdose crisis in Canada and additional strategies are needed,” write the authors.

“Physicians should be encouraged to practise patient-centred opioid prescribing.” They suggest removing barriers to medically supervised opioid agonist therapy to provide a safer alternative to illegal drugs and supporting harm reduction organiza-

tions to provide care to people using nonprescribed medications.

In a related commentary, Dr. Mark Tyndall, School of Population and Public Health, University of British Columbia, Vancouver, BC, writes, “In the last five years, the major responses to the overdose crisis have been to reverse overdoses through harm reduction programs, build a better addiction care system, and create better housing and social services. Although these may be important actions and aspirations in the long term, they will not address the current emergency. Unless there is a radical change in our approach to the epidemic, overdose deaths will continue unabated. It is time to scale up safe supply and decriminalize drug use.”

“Toxicology and prescribed medication histories among people experiencing fatal illicit drug overdose in British Columbia, Canada” was pubH lished August 24, 2020. ■ www.hospitalnews.com

IN BRIEF

Medical equipment in long-term care homes under the microscope in COVID-19 contamination study edical equipment, such as blood pressure cuffs, have been identified as surfaces at risk of COVID-19 contamination in long-term care homes, according to a Vancouver Coastal Health (VCH)-led study.

Vancouver Coastal Health took immediate action when the preliminary findings came to light. Shared blood pressure cuffs and other medical equipment at the sites were replaced with either disposable cuffs or dedicated equipment that is not shared between patients.

M

Vancouver Coastal Health collected samples at threeww long-term care homes during outbreaks of COVID-19 to better understand the extent to which environmental contamination occurs in long-term care settings.

Eighty nine surfaces were swabbed, including entrances, kitchens, staff communal areas, nursing stations and care areas. Six of the 89 samples tested positive for the SARS-CoV-2 virus responsible for COVID-19.

In all three facilities, the virus was detected on standard reusable blood pressure cuffs, for a total of four con-

Gender pay gap confirmed among physicians n the largest study of its type in Canada, the Ontario Medical Association has identified a 15.6 per cent unexplained pay gap between male and female doctors.

The OMA examined OHIP billings from 2017-18 which included nearly all doctors practising in Ontario and adjusted for certain factors, such as years of experience and work outside of business hours, to create an apples-to-apples comparison and found a gap of 15.6 per cent in daily billings that it cannot explain.

I

PAY EQUITY IS ESSENTIAL TO ENSURING THAT WE HAVE A DIVERSE MEDICAL PROFESSION

“The gender pay gap is an unfortunate reality that crosses all sectors” says OMA CEO Allan O’Dette. “With this report we can start to address how it impacts physicians. Hopefully, this work will lead to better equity not only for doctors but for all women.”

Significant variation in the unexplained billings gap was identiwww.hospitalnews.com

fied across specialty, geography, and practice setting (private vs. hospital).

These differences may be important to understanding how to better combat pay inequities.

The unexplained gap was the highest among general and family practice physicians at 19 per cent and lowest among surgeons at 10.2 per cent. The gap was highest in a semi-urban setting (19.8%), and lowest in rural settings (10.1%) with urban landing in the middle (13.5%).

“Pay Equity is essential to ensuring that we have a diverse medical profession” said OMA President Dr. Samantha Hill. “We have seen in many sectors that there are huge benefits to end users when there is increased diversity.

It would follow that patient outcomes will be improved by diversity in their physicians.”

Further study is needed into the definitive causes of the unexplained gap as well as potential solutions. Possible drivers have been identified during physician consultations including, patient characteristics, referral networks, fee codes and coding practices, mix of services, and other factors reflecting societal gender-biased expectations and systemic discrimination. OMA leadership is committed to deeper dives into identifying the causes and working towards system-level apH proaches to solutions. ■

taminated blood pressure cuffs of nine that were tested. The virus was also detected on the handle of a mobile linen cart and on the touch display of an electronic tablet used for electronic medication records.

“This study was done in sites with known outbreaks where enhanced cleaning was already in place, so we would hope that the virus would not be present on medical equipment that is moved from room to room,” says lead author Dr. Atiba Nelson, a Public Health and Preventive Medicine resident physician who led the environmental swabbing with a VCH team.

“Although more research is needed to determine if this kind of contamination could contribute to transmission of the virus, it did highlight areas of concern.”

While person-to-person transmission is believed to be the primary driver of outbreaks in long-term care

facilities, the findings, published this month in the American Journal of Infection Control, suggest medical equipment is a potential route for transmission of the SARS-CoV-2 virus. The authors of the paper recommend enhanced environmental cleaning for all medical equipment or prohibiting communal use of the equipment.

“The findings of the study have informed our response to long-term care outbreaks and highlight the need to be vigilant against COVID-19,” says VCH Medical Health Officer, Dr. Michael Schwandt, the co-author of the article. “Doing this type of research doesn’t just help us manage outbreaks now, it adds to the science on COVID-19 transmission so VCH and other health authorities have a better understanding of this new virus and so we can respond more effectively in H the future.” ■

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NEWS

A look inside a hospital laboratory during a pandemic

By Christy Janssens lthough often hidden from view, laboratory staff play a crucial role in determining whether someone has COVID-19.

Seven days a week, 24 hours a day, staff in Lab Services at St. Joseph’s Health Centre are working. They handle and test suspected COVID-positive patient samples, or patients under investigation (PUI). They discover who has COVID-19.

“Hospital laboratories are at the heart of medical decisions made by clinicians every day,” says Jeffrey Companion, Operations Lead within the Core Lab at St. Joseph’s. “Although the lab is not often seen, we are constantly at work to ensure our patients get the best care possible.”

The Lab Services teams at St. Joseph’s encompass multiple disciplines and departments tied together with one theme: handling and testing patient samples to support medical diagnosis and treatment.

The Phlebotomy team obtains blood specimens from inpatients and outpatients, ranging from neonates to the elderly.

The Transfusion Medicine team provides blood products in a safe, efficient and timely manner for routine and Emergency patient care.

The Chemistry team analyzes blood and other bodily fluids to support clinical investigations of metabolic and endocrine disorders, cancer, toxicology and serology.

The Immunology team identifies autoantibodies that cause various autoimmune diseases, and assesses immunodeficiency and other immune system disturbances.

The Hematology team tests for blood disorders like leukemia, anemia, coagulation disorders, and can also detect infection.

The Anatomical Pathology and Cytology teams provide histology services and examine cells and tissue

A

(above) Dr. Maria Pasic is the Clinical Chemist and Division Head of Immunology at St. Joseph’s Health Centre. (right) Jeffrey Companion is operations lead within the Core lab at St. Joseph’s Health Centre. components to aid in the diagnostic interpretation of disease processes.

The Microbiology team examines and identifies bacteria, fungi and viruses.

Point of Care testing is performed at the patient bedside to collect and rapidly analyze samples on the spot.

The tests performed by these teams provide important information for medical staff making treatment decisions. The teams work quickly, too, with many of the tests turned around within 30-60 minutes, says Companion.

The Phlebotomy team’s workload increased once the pandemic hit, says Yvette Williams, an Operational Leader in the divisions of Microbiology, Specimen Procurement and Pathology. They had an increase in blood draws and more PPE to put on before entering a patient room, but still needed to maintain expected turnaround times. As a result, they strengthened their resolve to support each other through this challenging time.

“The Microbiology staff pulled together as a team to navigate through the unprecedented increase in workload, primarily due to the number of Covid-19 swabs sent to the lab for testing,” says Williams “Their professionalism and dedication to each other and our patients remains unwavering.”

Inside the lab, the staff has donned more PPE to handle suspected or confirmed COVID samples, says Dr. Maria Pasic, Clinical Chemist and Division Head of Immunology. They installed new biosafety cabinets. They altered shift schedules to conform to social distancing protocols. They updated procedures to ensure uninterrupted testing for patients while minimizing the risks to staff. Additional Point of Care equipment was distributed to COVID units to ensure dedicated use and minimize exposure.

The Lab Information Systems team also created automatic alerts to signal every time a suspected COVID sample arrived to the lab.

Even though the pandemic placed strain on these teams, they have evolved to navigate the challenging times.

“Despite the difficult times and added safety procedures, our staff has maintained a positive attitude and willingness to adapt to the quick changes in the lab,” says Companion.

“They continue to put the care of our patients first. They have risen up to the title of ‘healthcare heroes’ during H this crisis”. ■

Christy Janssens is a communications intern at Unity Health Toronto.

8 HOSPITAL NEWS SEPTEMBER 2020

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NEWS

(left) Dr. Gregory Rutledge, Chief of Emergency Medicine at St. Joe’s says the virtual emergency visits are meant for individuals 18 years of age and older who are experiencing urgent but non-life-threatening concerns and who are unable to gain timely access to a family physician. (right) St. Joseph’s Healthcare Hamilton has launched an innovative program that offers virtual emergency department visits to patients, providing safe and fulsome medical assessments from the comfort of their own home or space.

Virtual emergency department visits

By Elaine Mitropoulos t. Joseph’s Healthcare Hamilton has introduced a new method of patient care to better meet the needs of the community; virtual care for emergency department services.

All it takes is a smart phone, tablet or computer to save a trip to the hospital.

“This service is meant for individuals 18 years of age and older who are experiencing urgent but non-life-threatening concerns, and who are unable to obtain timely access to their family physician, or for those who do not have a family physician,” says Dr. Gregory Rutledge, Chief of Emergency Medicine at St. Joe’s.

Same-day emergency department virtual visits are available to patients on a first-come, first-served basis. By filling out a virtual appointment request form on the hospital’s website, the patient is booked in to the next available opening on that day. At the appointed time, patients connect with an emergency department physician through a secure video portal.

The dedicated virtual care emergency department physician can ac-

S

commodate as many as 45 patients a day. Through the video visits, physicians provide fulsome and safe patient assessment and clinical recommendations for further treatment, including referrals to other care providers. Physicians can also prescribe new medication but cannot provide regular refills of medication already prescribed.

A TIMELY SOLUTION TO PROVIDING CARE

At the onset of the COVID-19 pandemic, the hospital’s emergency department saw a significant decline in visits. Physicians worried people with urgent issues needing assessment were choosing not to come to the hospital out of fear of contracting the virus.

“As St. Joe’s gradually reintroduces services and volumes at the hospital increase, having virtual options, including a virtual emergency department, helps to limit traffic in the hospital, while providing the right care to patients from the comfort of their own home or space,” Dr. Rutledge says.

A virtual appointment with an emergency physician may be the right

option for those experiencing an urgent medical issue that is not life threatening and who cannot obtain timely access to their family physician, or do not have a family physician.

Patients who are in severe medical distress should call 911, and should not drive themselves to the hospital.

Likewise, if symptoms worsen while waiting for a virtual appointment, it’s advisable patients visit the emergency department in person.

ACCESSING A VIRTUAL APPOINTMENT

Patients with a valid Ontario health card, and who meet the age requirement, can fill out the online registration form to be scheduled for a virtual appointment at St. Joe’s. Patients who are successful in securing a same-day appointment can expect to wait an average of one hour before hearing back.

Patients can use the service if they have access to the following: • Computer or mobile device with video and microphone capabilities • The Zoom application

• Internet access • E-mail (to access appointment link and reminders) • A quiet, secure space to engage in virtual visit Emergency physicians provide virtual appointments through a secure version of Zoom video chat integrated with Dovetale, St. Joe’s digital health information solution.

While virtual care sessions are not recorded, they will be documented in a patient’s electronic health record.

Moreover, notes from the virtual visit will be shared with a patient’s family physician through secure fax within 24 hours from a visit.

“Emergency departments and urgent care centres in Hamilton are still open for in-person visits, and are safe for those seeking care,” Dr. Rutledge adds. “Virtual appointments are an ideal option for anyone who might be hesitant about coming to hospital. In addition, this new care method may help with physical distancing requirements.”

To learn more about the program, H visit stjoes.ca/emergencyvirtualvisits. ■

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

10 HOSPITAL NEWS SEPTEMBER 2020

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NEWS

West Park Healthcare Centre plays a key role to free up ICU beds

By Raj Kohli and Dr. Roger Goldstein est Park’s newly expanded Long-Term Ventilation Unit (LTV) comes at a time when Intensive Care Unit (ICU) resources could become scarce in acute care centres, especially as they prepare for a potential second wave of COVID-19.

A great deal of the concern around a potential second wave is that the vast majority of people across Canada are still susceptible to the disease and that it could coincide with what is typically influenza season.

During the first wave of the COVID-19 pandemic, the Toronto Region requested that West Park expand bed capacity rapidly and our team acted fast, adding 23 beds to support intensive care units.

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West Park is also using its experience as the provincial LTV Centre of Excellence to take a lead role in moving medically stable ventilated patients out of the Greater Toronto Area ICUs into newly expanded LTV beds not only at West Park, but in partnership with two other Toronto hospitals. West Park and our partner hospitals are caring for patients who are invasively ventilated and occupying an ICU bed but could be moved to an alternative care setting, freeing up much needed ventilators and ensuring that ICUs are being used to their maximum benefit t should there a surge of COVID-19 cases arise.

LTV beds in post-acute care settings are in high demand, typically have a long waitlist, and serve those who have had an acute trauma or severe illness

such as ALS. During a pandemic, there is additional pressure to free up acute care space and the additional beds at West Park have allowed acute care partners to do just that.

West Park’s expertise in long-term ventilation and rehabilitation makes it an ideal partner in the effort to free up acute care ICU beds. Decision makers across the system realized some years ago that as people in an ICU become stable some still depend on a ventilator for life support and continue to occupy these beds without requiring ICU level of care. Transferring these patients is not only good from a system perspective; it improves the quality of life for these patients. West Park provides an environment enriched with recreational therapy, access to the outdoors and

the ability for families and caregivers to be active members of the care team.

For some of our patients, we provide comprehensive training to caregivers on mechanical ventilation, medication and personal care. This is complemented with therapy to optimize their physical, cognitive and emotional well-being. West Park collaborates with its external partners to follow the patients as they transition back to the community.

While we were pleased to be able to expand and contribute in wave one, the true benefit of West Park’s leadership and the expanded bed capacity will be during wave two. If that second wave hits differently and we do end up having packed ICUs, West Park will be H ready to assume its role. ■

Raj Kohli is the RRT Clinical Practice Leader- Respiratory Therapy Clinical Coordinator, Long-Term Ventilation Strategy and Dr. Roger Goldstein is Specialist, Respiratory Medicine and Senior Scientist at West Park Healthcare Centre.

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SEPTEMBER 2020 HOSPITAL NEWS 11

COVER

Air ambulance:

Cancel, or keep it coming?

Ornge launches project to improve timely access to trauma care for severely injured patients

By Dr. Brodie Nolan he phones in Ornge’s Operations Control Centre (OCC) ring 24 hours per day, seven days per week for air ambulance responses across Ontario. Ornge, Ontario’s provider of air ambulance and critical care transport services, transports the most critically ill and injured patients in the province. Approximately 95 per cent of Ornge transports are interfacility, or hospital to hospital, while the remaining transports are on scene trauma patients.

When Ornge receives a request for an on scene trauma response, the OCC will review all available and closest helicopters to respond. They will then contact the pilots of the closest and available helicopter to conduct a weather check to ensure it is safe to fly. The pilot will accept or decline based on weather and safety. During this process, or often times during the launch of the helicopter, Ornge may be cancelled for multiple reasons, some of which may include death, injuries not requiring air ambulance support or the patient has been transported directly to the hospital by the local paramedic service. Whichever the reason, Ornge is no longer requested to transport the patient at that time. Though, there are many circumstances where keeping an air ambulance responding may provide benefit to the patient.

Patients who are treated at a trauma centre have better odds of survival.

Likewise, a delay in receiving care at a trauma centre can result in patient

T

harm. It’s hard to talk about trauma systems without mentioning the concept of the “Golden Hour”, where there is a goal to get severely injured patients to a trauma centre within 60 minutes of injury.

The prehospital care system and emergency medical services therefore are an essential component within a trauma system and there is an incredible amount of coordination required to ensure that severely injured patients get appropriate care. For many patients, this involves bypassing a local hospital to go directly to a trauma centre. However, Canadian geography can present a barrier to prompt access to care. In fact, 40 per cent of patients in Ontario live further than a 60-minute drive to a trauma centre. These patients rely on an air ambulance scene response. Sometimes, however that system doesn’t work as well as it could.

A recent study of Ornge scene requests found that 35 per cent of trauma scene calls destined for Toronto trauma centres were cancelled, but yet 25 per cent of those patients were still eventually transported to a trauma centre. It also found this resulted in an average delay of 3.5 hours. Unfortunately, the reason why Ornge was cancelled was unclear over half the time.

To better understand the reasons behind trauma scene call cancellation, Ornge is beginning a project with the intent of improving timely access to trauma care for severely injured patients.

12 HOSPITAL NEWS SEPTEMBER 2020

COVER The project will involve many phases, the first of which is to obtain accurate, timely and actionable information on why Ornge is being cancelled from trauma scene calls. The purpose is to understand why Ornge is being cancelled from a call and to follow-up to see if patients are eventually transferred to a trauma centre or are able to have appropriate care provided at their local hospital.

Going forward, when Ornge is being cancelled from a trauma scene call, they will be asking the attending paramedics and Ambulance Communications Officer (ACO) to provide one of the following four reasons: • Patient did not meet Field Trauma Triage Standards • Land EMS taking the patient directly to trauma centre • Patient is pronounced deceased • Patient refusing transport If the ACO has not obtained this information from the attending paramedics, when possible, they will contact the crew directly to confirm the reason.

It’s important to remember that, in many cases, there is an alternative option to cancelling the air ambulance which could help reduce delays in transport. In instances where the local responding paramedics have cancelled an Ornge response and transported the patient to a local

hospital, it is recommended they update the OCC and responding Ornge crew as to the patient’s condition and the hospital they are transporting to, rather than cancelling. This would allow Ornge to coordinate what’s known as a “modified scene response.” – This occurs when Ornge

is dispatched to an alternate landing site which is not the geographic location of an incident. The Ornge crew can rendezvous with the land Paramedic Service, either at the hospital or on route, for patients who may still require transport to a trauma H centre. ■

Dr. Brodie Nolan is an Ornge Transport Physician and Trauma Team Leader at St. Michael’s Hospital in Toronto.

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NEWS

Digital tools and virtual care in emergency services ith Ontario undergoing a phased reopening, emergency department volumes, which dropped during the first few months of the COVID-19 pandemic (see sidebar), are beginning to normalize. That, along with planning for possible future outbreaks, has highlighted opportunities for virtual models of care to help optimize access to emergency services and keep patients safe. Virtual models of care can assist in assessment, allow providers to offer self-care advice, and direct patients to appropriate care settings. Beyond improved access, however, they can also enable enhanced patient choice, maximize hospital and health system resources, and improve convenience for patients and their families.

The Electronic Canadian Triage Acuity Scale, or eCTAS, developed

by Cancer Care Ontario (now a business unit of Ontario Health), has been instrumental in improving patient safety and quality of care by enabling consistent triage since it first launched in 2017. eCTAS has also been a key enabler in providing insight into emergency departments trends for health system planning and management.

Now used in 115 Ontario hospitals, the cloud-based, electronic, triage decision-support tool is primarily used by front-line nurses to calculate an acuity score based on combinations of 169 different presenting complaints – such as chest pain, confusion or vomiting – and more than 400 other variables, including pain level or fever. Today, more than 90 per cent of all emergency-department patients in Ontario are triaged using eCTAS, which also shares real-time data and information, including infection-control updates from Public Health Ontario. Research has demonstrated eCTAS has improved consistency and accuracy of triage significantly, and it can certainly be further leveraged in pre-hospital settings to enhance virtual emergency care.

W

Emergency Department Visits in Ontario January February March April May June

2019 494,726 444,589 500,642 491,389 507,590 499,788

2020 512,552 450,598 376,971 245,750 332,449 394,258

Source: National Ambulatory Care Reporting System (NACRS) provided by Canadian Institute for Health Information (CIHI)

OTN, the virtual care division of Ontario Health, has been working closely with its Cancer Care Ontario unit and hospital partners to support two key facets of emergency care remotely: clinical assessment and treatment for non-life-threatening concerns.

The potential upside is considerable.

Patients seeking medical care or advice and who may be considering a trip to an emergency department, for instance, could log on to a hospital webpage that includes ED information and a live link to initiate a virtual visit from their own device. An individual could then be assessed in one of three ways: through direct contact with an attending phy-

sician, or triaged remotely by either an actual nurse (using a tool like eCTAS) or an artificial-intelligence platform, such as a chatbot using sophisticated algorithms, that pre-screens them before connecting them with a clinician.

After triage, that same patient can then be placed in a “virtual waiting room” to see an available physician based on acuity score or sent a scheduled time via text or email for a video or audio visit.

Prescriptions or lab tests could also be ordered when appropriate – or, if necessary, the patient could be redirected to an in-person emergency department or an appointment with a primary care provider.

Two great examples of virtual care in Ontario that have shown promise in relieving pressure on emergency departments can be found at Ottawa-based CHEO and the Renfrew County Virtual Triage and Assessment Centre (RC VTAC). The latter connects OHIP-insured Renfrew County and South Algonquin residents unable to access a primary care provider to a family physician or nurse practitioner for non-threatening health concerns, 24/7, including for COVID-19. (Those who suspect they may be having a heart attack or stroke or who are experiencing major bleeding or severe breathing problems should still contact 911.) After calling a special number (1-844-7276404) and answering some basic health questions posed by a medical receptionist, patients are either directed to seek immediate emergency care or are booked into a same-day video or telephone appointment.

CHEO, meanwhile, in early May became Canada’s first pediatric hospital offering a virtual emergency department for similarly non-life-threatening medical concerns. Families are first asked to reach out to their primary care physician or pediatrician, but in the event they are unavailable they can visit www.cheo.on.ca, where, after completing a self-triage assessment to determine suitability, they can book a same day video visit with an emergency physician specializing in pediatric care. Since early May, 81 per cent of all CHEO’s virtual ED visits avoided the need for an in-person visit at the hospital.

Hospitals and care organizations, including Ontario Health Teams, interested in further exploring how virtual access to emergency care can help patients during the pandemic – and beyond – are encouraged to visit the COVID-19 online resources of Ontario Health (OTN), Ontario Health’s virtual care system response H section or email info@otn.ca. ■

This article was submitted by the Ontario Telemedicine Network.

14 HOSPITAL NEWS SEPTEMBER 2020

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NEWS

Ensuring exceptional and safe care in hospital and at home

By Sarah Quadri

or Peggy Weatherall, there’s no place like home. Curling up in the comfort of her favourite, green afghan that she hand-knit years ago, admiring the painting of her wedding portrait on the wall in the living room and savouring the smell of perfectly cooked toast coming from her kitchen – even though she finished breakfast hours ago. Home means so much.

Peggy is a longtime resident of the Niagara region and was once an avid Sudoku player. She also managed payroll in the Royal Navy in the late 1940s, before coming to Canada. As a 92-year-old with dementia, that feeling of being in a familiar place and surrounded by the things and

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people she knows and loves – nothing compares.

No one knows that feeling better than Bob Weatherall, 93, Peggy’s husband for over 70 years and her primary caregiver. “It’s been very hard for me,” admits the kind and soft-spoken, retired Royal Navy officer – also a trained electrical engineer. “Then, when Peggy fell and broke her wrist in March, it was even more difficult.

But having an amazing team, caring for my wife and for me is wonderful. I can’t thank them enough and I am so happy to have her home.”

Earlier this year, Peggy was part of the Niagara Health@Home Transitions Program – an exemplary ‘one team’ partnership between Niagara Health, a multi-site hospital

with a growing network of virtual and community-based services, and SE Health, one of Canada’s largest health care providers, caring for people in their homes and communities for over a century.

The Program, funded by the Ontario Ministry of Health as part of its September 2019 announcement – to expand home and community care, to end hallway health care and to build more capacity in communities across Ontario – strengthens patients’ connections to the hospital and home care providers and delivers 24/7 care and support to patients, for up to 16 weeks, in the places they call home.

Through the creation of personalized, post-discharge, holistic plans of care, the Program decreases the amount of

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time patients spend in hospital and ensures their safe transition from hospital to home. These care plans also promote assistance beyond medical care and may include help with social connections, meals and housing.

The interdisciplinary care team includes nurses, personal support workers, physiotherapists, social workers and registered dietitians, to name a few. The emphasis on home care ensures that acute care hospital beds are available for patients who need them most.

“This program is an outstanding example of the innovation taking place at Niagara Health and beyond our walls to ensure patients get the best possible care in the most appropriate setting.

Continued on page 19

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SEPTEMBER 2020 HOSPITAL NEWS 15

NEWS

COVID-19 highlights value of video laryngoscopy

By Patrick Nellis and Eliana Landori

REDUCING RISK

In emergency departments and intensive care units across the country COVID-19 has changed the way hospitals operate. With an increased need to support patients in respiratory distress, a new focus is being placed on video laryngoscopy (VL) for intubating patients being put on a ventilator.

VL has won growing acceptance because the enhanced visualization makes it more likely intubation will be successful on the first try, making the process safer for physicians and patients compared to traditional direct laryngoscopy (DL). Additionally, VL reduces the risk of spreading a highly contagious virus.

“The availability of a video laryngoscope at every intubation minimizes errors and unforeseen difficulties, enhances feedback, learning and teaching,” says Marco Zaccagnini, Registered Respiratory Therapists/Certified Clinical Anesthesia Assistant. “It shares the intubation with the medical team and provides a safer environment for both the operators and patients.”

TRADITIONAL INTUBATION

Endotracheal intubation involves inserting a plastic endotracheal tube through the mouth or nose, through the larynx (which includes the vocal cords), and finally into the trachea (windpipe). The tube is guided into place with a device known as a laryngoscope, before being attached to a ventilator.

In a conventional DL intubation, the physician can see the tip of the laryngoscope as it enters the mouth, but must then rely on “feel” and experience to make sure it avoids the esophagus and is positioned correctly. Direct laryngoscopy can be difficult with some patients. Obtaining a view of the

larynx is key to this technique and can be influenced by factors such as the structure and mobility of the neck and jaw, as well as the anatomy of the upper airway.

Intubation is a common procedure, even more so during the COVID-19 epidemic, but it’s not risk-free. On occasion, damage may be done to the teeth, mouth or trachea, and the laryngoscope may be inserted accidentally into the esophagus. Sometimes the first laryngoscopy attempt is unsuccessful, requiring subsequent attempts. The risks to the patient increase with the number of attempts. In COVID-19 cases, healthcare providers performing laryngoscopy can be at higher risk of contracting the virus.

DL is challenging to master, but with experience, anesthesiologists and respiratory therapists become proficient with this technique and often find success on the first-pass attempt.

Studies have shown, however, that

medical students and novice anesthesia residents have significantly lower initial success rates than experienced anesthesiologists.

LATEST EVIDENCE

Video laryngoscopy, on the other hand, is easier to learn because it provides visual confirmation of the progress of the breathing tube into the trachea. This improves the likelihood that intubation will be successful on the first attempt even if the healthcare provider is inexperienced, or if the patient’s condition makes the procedure difficult. With VL, a camera on the end of the laryngoscope provides an enhanced view of the upper airway, including the vocal cords, displaying video images in real time on a screen attached to the laryngoscope’s handle.

The higher success rate for VL was confirmed in a 2019 study led by Dr. Ruediger Noppens, associate professor of anesthesiology at Western

University in London, Ontario. This international trial involved more than 2,000 patients and compared the firstpass success rate of intubations using a standard direct laryngoscope and a McGrath MAC video laryngoscope, made by Medtronic.

The study found that VL had a firstpass success rate of 94 per cent, compared with 82 per cent for the DL, and also resulted in less patient injury. According to Dr. Noppens, this study was the first real evidence to support the use of VL for routine intubations. The researchers concluded that the only advantage of DL was cost, although the higher initial expense of the video device may be outweighed by savings in time and medical complications.

That’s good news for emergency and ICU doctors, who typically perform fewer routine intubations than anesthesiologists. VL is also safer for physicians dealing with COVID-19 because they don’t have to get as close to the patient’s face as they do with a DL. It’s safer for patients too, because it results in fewer injuries.

As hospitals scramble to treat patients with severe COVID-19 infections, professional societies in many countries have begun recommending the use of VL to help mitigate the spread of the virus. These recommendations stem from evidence of improved first-attempt intubation success and increased distance between the provider and patient during the procedure.

Although the advantages of VL are becoming increasingly clear, DL remains the standard of care in Canada, while VL is often reserved for difficult intubations. The future of VL is currently the subject of debate within the anesthesia community, with many believing the real question isn’t whether it will replace DL as the standard of H care, but when. ■

Patrick Nellis, a former respiratory therapist and anesthesia assistant, and Eliana Landori, work in the Respiratory & Monitoring Solutions division of Medtronic Canada.

16 HOSPITAL NEWS SEPTEMBER 2020

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Brian’s all in.

Brian Cameron likes to win. Be it in the courtroom, or playing poker in his downtime, this hardworking lawyer knows how to keep his cards close to his chest, which may be one reason why he’s at the top of his profession.

As a personal injury litigator, Brian gets satisfaction from the opportunity to make a difference in the quality of his clients’ lives, especially when they may not yet be aware of the hand that they’ve been dealt.

What makes him a good poker player also helps him win cases. “I see myself as a storyteller. I share my client’s life story with the jury so they can see how drastically the defendant has changed their life … and I have a good poker face when I need one.”

Brian excels at breaking down legal complexities to their simplest form for his clients.

He treats them with a level of dignity and compassion that has contributed to his being recognized as a certified litigation specialist. That kind of passion, commitment and dedication means that Brian’s all in when it counts the most.

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SAFE MEDICATION

Virtual care in a virtual world

By Crystal Zhang, Gigi Lai, and Certina Ho am currently under self-quarantine and I’m confused about the new prescription delivered to me this afternoon. Can you help me?”

With limited face-to-face interactions during COVID-19, technology has played an increasingly crucial role to ensure safe and effective medication use and the continuity of patient care.

AS MEDICATION EXPERTS, PHARMACISTS CAN UTILIZE VIRTUAL CARE THROUGHOUT THE MEDICATION USE PROCESS WHEN INPERSON INTERACTIONS ARE LIMITED OR NOT FEASIBLE.

“

I

WHAT IS TELEHEALTH?

“Telehealth” refers to the use of technology (e.g. phone calls, smartphone applications, video calls) to facilitate remote communication between patients and healthcare providers with the purpose of promoting clinical care. Telehealth is definitely not a new concept. Traditionally, barriers including lack of support for technological infrastructure and concerns regarding patient privacy have limited its adoption. However, social distancing measures enforced for COVID-19 have led to a surge in digital healthcare tools. Videoconferencing and audio calls provide patients with access to healthcare providers for those who may be self-isolating or immunocompromised, or who may have mobility challenges or difficulties in physically accessing healthcare, among other reasons.

As healthcare delivery enters the age of technology, telehealth is certainly here to stay beyond the pandemic. How can we, as healthcare providers, leverage the advancement in technology to improve patient care?

ROLE OF PHARMACISTS IN VIRTUAL CARE

Let’s take a look at how pharmacists, for example, can use or have adopted telehealth to enhance healthcare. As medication experts, pharmacists can utilize virtual care through-

out the medication use process when in-person interactions are limited or not feasible.

Before prescription order entry A best possible medication history (BPMH) is a complete and up-to-date list of a patient’s medications along with other health information including medication allergies, medical conditions, and social history. With telehealth, pharmacists can conduct BPMH interviews with patients (or patient caregiver), identify and resolve medication discrepancies, and prevent miscommunications among healthcare providers within the patient’s circle of care. When new medications are prescribed, an up-to-date profile can help pharmacists identify/prevent potential drug therapy problems and optimize medication regimens accordingly.

During preparation of a prescription Medication regimens can be overwhelming for patients, especially when undergoing emotional stress from a newly diagnosed condition. Therefore, pharmacist-patient communication is important in helping patients understand their medication(s) and achieve safe and effective therapeutic outcomes. For instance, pharmacists can demonstrate medication administration techniques (e.g. for inhalers) through videoconferencing and provide counselling on medications over the phone. Similarly, patients can use telehealth to connect with pharmacists, ask questions, and clarify concerns regarding their medications.

Medication therapy management After a new medication is initiated, it is important to monitor the efficacy of the treatment option, check for any potential adverse effects, and evaluate patient’s adherence to the therapy.

Undoubtedly, telehealth allows for greater accessibility as pharmacists can monitor patients over the phone or via videoconferencing. At the same time, patients can connect with their pharmacists remotely to discuss concerns regarding their medications. Additionally, telehealth enables pharmacists to virtually collaborate with prescribers to resolve drug therapy problems and optimize patient care.

IS VIRTUAL CARE FOR EVERYONE?

Despite the benefits of telehealth, patient factors and technological security should be considered before implementing virtual care. Remote communication is not a replacement of, but rather an alternative or a complementary option to, in-person visits.

Patient factors, including the type of assessment required from a healthcare provider and a patient’s technological literacy, are important considerations when determining a patient’s eligibility/suitability in using and/or receiving care via telehealth. Sometimes, video calls alone are not adequate if physical assessments are required (e.g. for chest pain); face-to-face follow-up visits may be necessary for comprehensive examination and care. On an-

other note, the security, privacy, and confidentiality of virtual platforms in providing and supporting telehealth should be carefully evaluated. Before a virtual care interaction, an informed consent from patients pertaining to potential risks associated with telehealth communication should be obtained by the care provider. While telehealth has brought convenience to healthcare, its limitations should always be acknowledged to ensure not only patient safety, but also equity, diversity, and inclusion.

GOING FORWARD

COVID-19 has significantly accelerated the development and adoption of telehealth, advancing healthcare into the digital age. Telehealth can be considered as a complementary tool to enhance patient care. However, it is imperative that healthcare providers evaluate the appropriateness of virtual care according to individual patient care needs and carefully assess the security of telehealth platforms in order to maintain continuity of patient-centred care.

The Canadian Medical Association, together with the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada, developed resources and tools to help physicians and patients adopt virtual care. For example: • Virtual care: Recommendations for scaling up virtual medical services (https://www.cma.ca/virtual-care-recommendations-scaling-virtual-medical-services) • Virtual care playbook for Canadian physicians (https://www.cma. ca/sites/default/files/pdf/Virtual-Care-Playbook_mar2020_E.pdf) • Virtual care guide for patients (https://www.cma.ca/how-navigate-virtual-care-visit-paH tient-guide) ■

Crystal Zhang and Gigi Lai 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.

18 HOSPITAL NEWS SEPTEMBER 2020

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NEWS

Post-pandemic Continued from page 4

Niagara Health and SE Health are collaborating in an innovative, ‘one team’ partnership, delivering exceptional and safe care in hospital and at home to patients in their Niagara Health @ Home Transitions Program. From left to right: Katharene Gill, SE Health PSW Team Lead; Peggy Weatherall and Bob Weatherall.

Ensuring exceptional and safe care Continued from page 15

Providing consistent and coordinated care in the hospital and at home will help to improve patient flow, provide safe discharges, and better connect patients with services in the community,” said Derek McNally, Executive Vice-President Clinical Services and Chief Nursing Executive at Niagara Health. “We’re proud to be leaders in the shift to community-based care – working with our partners, including SE Health, to deliver extraordinary care to patients and families in Niagara.”

“This innovative model is reinventing how we deliver authentic patient and family-centred care,” said Nancy Lefebre, Chief Clinical Executive and Senior Vice President of Knowledge and Practice at SE Health. “Using an interdisciplinary care approach, we are enhancing trust between patients, families and caregivers, while offering a seamless transition from hospital to home. We are thrilled to be collaborating with Niagara Health, allowing us to deliver home care services that are providing tremendous support for our patients, families and caregivers and optimizing independence for our patients. We look forward to building on this partnership and nurturing other transition program partnerships – with hospitals across Ontario – to continue

delivering exceptional, personalized care at home.”

The Program began in St. Catharines in November 2019 and has since expanded to Niagara Health’s Welland and Greater Niagara General sites.

The overall goals: safe and timely transitions and helping people stay at home; better self-care management for patients; and reducing the need for Emergency Department visits or readmission to hospital. The Program has helped close to 150 patients, like Peggy, transition safely from hospital to home and the feedback is amazing.

“Every day, I looked forward to them coming into our home,” said Bob Weatherall, with a big smile. “They are so friendly and they make sure Peggy is cared for in every way. I couldn’t have gotten through without them. They also freed up a hospital bed doing this,” he added. “It’s just Peggy and I at home and this wonderful team created a different atmosphere when they were here – you have to experience this level of care for yourself.”

“In my 35 years of nursing, I can say with confidence that this is an outstanding team who gives everything to put patients first, at all times,” said Colleen Monteith, SE Health Transitions Program Care Lead, Niagara Health@ Home. “It’s an extremely well-rounded

Sarah Quadri is the Director, Corporate Communications at SE Health. www.hospitalnews.com

program with numerous benefits to the patients. We also provide excellence in health teaching to the patient and their family or caregiver. If, at any time, they have a health issue, they don’t go back through the Emergency Department, we are always here to help – there is exceptional continuity in care.”

“This is one of my favourite life experiences,” said Katharene Gill, SE Health PSW Team Lead, Niagara Health@Home. “We always work as a team and anytime something comes up we mobilize the resources that are needed. “Julie K, our SE Health Physiotherapy Assistant, worked wonders with Peggy. Bob said he has never seen Peggy get up and want to do exercises the way she did with Julie.”

Although Peggy Weatherall had some health challenges, she completed the 16-week program with safe and exceptional care, and a “special team of new friends.”

“On behalf of Peggy and myself, I would like to express my profound gratitude to everybody in this program, for their devotion, professionalism, patience and above all, their sincere friendship in our time of need,” exclaimed Bob Weatherall. “You’ve taken a tremendous load off my shoulder and we will miss you; you will stay in H our hearts forever.” ■

Instead, recovery plans that commit to social equity – remedying disadvantage and exclusion, while promoting health and well-being – will protect our communities and societies from future harm.

We need meaningful and lasting policy change at both the domestic and international levels.

At home, this means being attentive to COVID-19’s gendered impacts on the economy and rejecting recovery measures that are not responsive to those realities. Ensuring access to affordable child care and the full (but safe) re-opening of schools in September. Fundamentally reforming long-term care. Spending to close the gaps in education and employment for groups that have long been marginalized and discriminated against. Ensuring access to housing, food and other basic necessities. Overhauling policing, criminal justice and incarceration policies. Extending rather than retracting environmental protection measures.

And taking decolonisation and nation-to-nation relationships with Indigenous peoples seriously.

In short, it means that governments should spend their way out of the downturn in ways that respond to the structural inequities that prevent individuals and communities from thriving.

This is the path to social and economic well-being as well as social justice.

Internationally, Canada must help create a more equitable global order.

In 2019, Canada’s foreign aid budget was a dismal 0.27 per cent of Gross National Income. This amount is lower than Canada’s foreign aid flows under the Harper Government. But it cannot be just about money. The world has learned that the world order, and the health of people everywhere, can be held hostage by one or two governments. That cannot be allowed to continue.

Recovery plans must control infections and rebuild sustainable economies. But they also need to acknowledge our shared futures, and that we are all vulnerable in this deeply interconnected and yet deeply unequal H world we have created. ■ Vanessa MacDonnell, Sophie Thériault and Sridhar Venkatapuram are three of the editors of Vulnerable: The Law, Policy and Ethics of COVID-19

SEPTEMBER 2020 HOSPITAL NEWS 19

ONLINE EDUCATION

Embracing technology in grass-roots conferences

By Roger Boyle vercoming challenges related to the COVID-19 pandemic is not new for healthcare workers.

In addition to meeting the needs of patients and communities during these challenging times, a team in UHN’s Laboratory Medicine Program (LMP) recently held its first completely online continuing education (CE) conference, supporting education for the broader medical community and raising nearly $15,000 for charities confronting COVID-19.

“The key intent behind the conference was to make it as accessible as possible,” says Ian Sue-Chue-Lam, pathologists’ assistant, LMP and lead organizer of the Online Surgical Pathology CE Conference.

O

Photo credit: UHN Surgical Pathology

In addition to engaging in a wide-range of diagnostic presentations, participants of the Online Surgical Pathology Conference were virtually taken into UHN’s lab space for neurology and cardiovascular specimen workshops led by pathologist, Dr. Michael Seidman.

“By making it ‘donate what you can’ with all proceeds going to charity, we felt like we could bring together as many people as possible to get behind the message and collaborate.”

Positioned for success Kristin is evidence that the online Master of Health Management (MHM) Program positions students for success, and enhances their career growth. She believes “the MHM Program teaches leaders crucial translational knowledge that can impact and elevate a student’s personal and professional life, as well as the quality of healthcare in Canada.”

When she embarked on her MHM journey, Kristin was Operations Manager of a Neurosurgery & Stroke at a large hospital in Windsor, Ontario. Here, her greatest accomplishment was the establishment of a 16-bed acute stroke unit. In her second year of the Program, she was promoted to the position of Director of Critical Care &Cardiology. And currently, Kristin is the Vice President of Patient Services & Chief Nurse Executive at Erie Shores Healthcare.

“Without the foundational learnings of the MHM Program I know that I would not have had such a swift trajectory in this part of my career. As I have overseen the development of quality initiatives and a standard model of care I have leveraged the theory of each class as a source of reference and opportunity”, she says.

More than 350 participants from across 16 countries attended the online conference for presentations on cancer diagnostics, and virtual in-lab sessions on surgical pathology – where viewers learned how to handle and study surgically resected tissue samples and organs to diagnose disease.

institutions to spread continuing education out to a much wider audience, including peripheral professionals, who otherwise wouldn’t have access to this.”

Registrants in the post-event survey, which showed a 98 per cent satisfaction rate, shared this sentiment with many comments commending the accessibility and overall use of technology. One person wrote that it was a long overdue, given the modern era.

“The pandemic has really put a lot of pressure on people to figure out ways to come together online,” Ian says. “These methods have always been available, but we have never collaborated internationally to create an event like this until now.

“I think we’re seeing technology play a bigger role in the way that people engage with one another and interact with their communities.”

WHILE FORCED TO BE PHYSICALLY APART, UHN’S SURGICAL PATHOLOGY TEAM IS USING TECHNOLOGY TO BRING PEOPLE TOGETHER FOR CHARITABLE CONTINUING EDUCATION. Presenters, many of whom were scheduled for in-person conferences no longer able to take place, readily joined the initiative, sharing their expertise remotely from five different states and provinces across North America.

“The thing that impresses me the most, along with increased accessibility,” says Martin Grealish, senior pathologists’ assistant, LMP, and co-organizer of the conference, “is the overall inclusiveness of the initiative.

“We pulled together multiple professional organizations, industry sponsors, and speakers from various

The conference, held live on June 6, took just over two months to plan.

Due to high demand, organizers held a second day of presentations on July 25.

“This was a grass-oots effort that Ian did a fantastic job of leading,” says Martin. “It also really speaks to the opportunities that are out there if we can start leveraging more IT tools and increasing access to educational resources.

“The potential for growing this is huge, for all of our professions at UHN. All it can do is grow from H here.” ■

Roger Boyle works in communications at University Health Network.

20 HOSPITAL NEWS SEPTEMBER 2020

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Online graduate degree: offering part-time and full-time options

Master of

Health Management Bridging the gap between health professional and health management healthmanagement.mcmaster.ca

ONLINE EDUCATION

Surgeons in training use virtual reality to sharpen skills

By Elaine Mitropoulos hrough virtual reality technology, St. Joseph’s Healthcare Hamilton, a teaching hospital affiliated with the world-renowned McMaster University, continues to provide cutting-edge educational experiences that are allowing orthopaedic surgeons in training to sharpen their skills during the pandemic.

Dr. Vickas Khanna, Orthopaedic Surgeon at St. Joe’s and Orthopaedic Surgery Residency Training Program Director at McMaster University, says the virtual technology is filling a void in training residents while restrictions imposed by COVID-19 are in place, including limitations on elective surgeries.

“Pilots do much of their training in a simulator before actually flying a plane,” Dr. Khanna says. “This technology is similar. Residents can become adept at doing a surgery virtually before doing it in real life with confidence.”

With a head set and two controllers that act as surgical tools, the unique technology simulates elbow, knee, and hip replacements. The platform

T

With a head set and two controllers that act as surgical tools, St. Joe’s orthopaedic surgeons in training are able to perform common surgeries on realistic, life-like patients – from implant to positioning to drilling and hammering. allows the residents to perform surgery on realistic, life-like patients – from implant to positioning to drilling and hammering.

Before the pandemic, Dr. Marianne Comeau-Gauthier, a first-year resident, was in the operating room train-

ing almost daily. Today, virtual reality allows her to continue to advance her skills while the hospital gradually resumes elective surgeries.

“With virtual reality, you are completely in another world and can practise and focus on the task at hand,”

she says. “It’s something every resident should do before going into the operating room.”

Dr. Muzammil Memon, a St. Joe’s resident in his third year, says virtual reality training complements traditional surgical training.

“Virtual training walks you through complicated surgical steps so you can build an internal rhythm for what comes next,” he says. “It’s an experience residents wouldn’t necessarily get watching a real-life surgery in the operating room.”

Dr. Khanna foresees other surgical specialties at the hospital leveraging virtual reality training during the pandemic, and long after it’s over.

“With virtual reality, you can go back over complicated procedures.

In a real operating room, you can’t cut twice,” Dr. Khanna says. “My hypothesis is those who train virtually will be more prepared, confident, and comfortable with surgeries in the real world.”

Interactive virtual reality training is being delivered to the hospital’s orthopaedic surgeons in training through H the Precision OS platform. ■

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

22 HOSPITAL NEWS SEPTEMBER 2020

www.hospitalnews.com

ONLINE EDUCATION

Free online COVID-19 resources for health providers he American Lung Association and Cleveland Clinic announced an educational collaboration to disseminate free, comprehensive resources on COVID-19 care for healthcare providers globally. The resources inform best practices to care for critically ill patients in a variety of clinical settings during the COVID-19 pandemic.

The robust inventory of online evidence-based modules and quick reference guides, developed by a multidisciplinary team of Cleveland Clinic experts, is hosted in Cleveland Clinic’s Respiratory and Education institutes’ Comprehensive COVID Care platform. The American Lung Association’s support of this comprehensive resource for healthcare providers is made possible through the organization’s $25M investment in the COVID-19 Action Initiative. These

T

resources expand the organization’s existing science-based resources on COVID-19 for the public at Lung.org/ covid-19.

“Too many lives have been lost to COVID-19. As our nation and world face the pandemic, our healthcare providers need and deserve support and advanced training specific to this new virus,” says American Lung Association President and CEO Harold Wimmer. “To save more lives and protect our frontline workers, we need to equip our nation’s healthcare providers with the most recent and up-to-date knowledge about COVID-19. The American Lung Association is proud to provide educational resources for healthcare providers about COVID-19.”

This educational platform assists interprofessional and interdisciplinary teams to standardize practices in the care of patients during the COVID-19

pandemic. The web-based learning platform provides up-to-date, relevant and easy-to-access information germane to the position where a provider might be deployed. The resource has been categorized into three groups:

COVID-19 CAREGIVER RESOURCE

For healthcare workers who provide care to COVID patients.

Features ICU and non-ICU management guidelines to be used both in preparations for deployment and as a real-time management guide in the care of COVID-positive patients.

Includes resources on different procedures for airway management, vascular access, mechanical ventilation and key modifications to current advanced care life support processes specific to the COVID patient experiencing cardiac arrest.

APPROACHES TO THE NON-COVID PATIENT

Addresses a wide variety of critical care and non-critical care topics appropriate for providers in both the ICU and non-ICU inpatient settings.

These modules are intended to be used as a primer for pre-surge provider preparation and as refresher materials.

Each major section includes both disease-specific and process-specific modules or guides.

JUST-IN-TIME

Is intended to be used by providers as a care management reference guide. These provide quick access to a wide range of checklists, how-to guides and quick references on disease state, diagnosis, preventive measures and strategies for patient care and H treatment. ■

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ONLINE EDUCATION

Creating new opportunities during COVID-19

By Anna Wassermann f you ask Drs. Marcus Burnstein and Shiva Jayaraman about working through COVID-19, they’ll tell you that challenging environments often create new opportunities. That’s how they explain the way physicians from St. Joseph’s Health Centre and St. Michael’s Hospital came together to unify cancer care.

For more than a decade, physicians at St. Joseph’s and St. Michael’s have had site-specific multidisciplinary cancer conferences (MCCs), where specialists from different disciplines discuss the diagnosis and treatment options of patients. During COVID-19, virtual tools helped the hospitals integrate their MCCs in a new way.

I

Moving multidisciplinary cancer conferences online has ensured cross-site collaboration in cancer care.

“We were forced to take a step back from our standard practices and engage in virtual care,” says Dr. Burn-

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stein, a colon and rectal surgeon at St. Michael’s and head of the hospital’s Gastrointestinal (GI) MCC. “Once we did this, we started to realize how conducive video conferencing is to cross-site collaboration and how much we enjoyed connecting with our peers across the network.”

Since April, nearly a dozen surgeons, medical oncologists, pathologists and radiologists at St. Joseph’s and St. Michael’s – as well as a radiation oncologist from Princess Margaret Cancer Centre – have connected weekly over Zoom to discuss GI and HPB cancer cases at Unity Health. These meetings amplify the pace of consultation and help each patient get the appropriate tests, treatment options and recommendations.

“It’s a great quality control metric,” says Dr. Jayaraman, a hepatobiliary and pancreas surgeon at St. Joseph’s and head of the hospital’s GI and Hepatopancreatobiliary (HPB) MCC. “You’re getting a second, third and fifth opinion in one meeting, while the breadth of subspecialties allows for tailored multidisciplinary care.”

By integrating, each hospital capitalizes on the other’s expertise. This reduces the number of cases that need to be referred elsewhere.

The combined MCCs have also been helpful during COVID-19. “As we continue to work through the pandemic, the MCC allows our decision making and subsequent care to be more efficient,” says Dr. Jayaraman.

As services ramp up, Drs. Jayaraman and Burnstein say they look forward to realigning MCCs across the organization – including for GI and HPB, breast cancers and others. They add that Zoom is here to stay.

“Little is lost in collaborative, collegial spirit when we connect virtually,” says Dr. Burnstein. “It’s improved our efficiency, allowed for more participation and taken away the logistical challenges associated with planning weekly in-person meetings, especially during COVID-19.”

Dr. Jayaraman echoes this and is quick to credit Unity Health’s Telemedicine team for the way they enabled virtual connection and improved cancer care across the organization.

“The Telemedicine team allowed us to ensure high-quality care for our patients during the pandemic,” he says.

“But they also brought us together as a network of cancer providers to ensure that moving forward, patients at Unity Health receive the best access to qualH ity multidisciplinary care.” ■

Anna Wassermann is a communications advisor at Unity Health Toronto. www.hospitalnews.com

ONLINE EDUCATION

Online education package readies health professionals to be redeployed to provide COVID-19 care ith the rapid rise and severity of COVID-19 cases, hospitals were concerned that they would urgently need healthcare professionals to redeploy to critical care environments.

To enable this redeployment, a team led by the Michener Institute of Education at UHN worked with experts from across the Toronto Region to create an online education package to ensure healthcare workers have the information they need to safely care for COVID-19 and other critically ill patients.

These educational materials are available for clinicians at criticalcarelearning.ca.

The resources on the site are intended for healthcare providers such as anesthesia assistants, nurses, physicians, physician assistants, physiotherapists, occupational therapists, registered dietitians and respiratory therapists, who are involved in the care of COVID-19 and other critical care patients.

W

www.hospitalnews.com

Anyone in these professions wishing to access the site should connect with their Ontario hospital clinical director or manager for the access code and instructions.

The site also includes resources on palliative care and bioethics, as well as team-based models of care, team wellness and resilience to ensure healthcare workers are supported to take care of each other and themselves through the pandemic. More professions, such as personal support workers and pharmacists, and resources will be added in the next phase as redeployment strategies evolve.

The rapid development and delivery of the criticalcarelearning.ca resources was led and supported by a highly-skilled and collaborative regional team of educational experts, clinicians, academics and leaders across the region.

DID IN 10 DAYS WHAT WOULD TYPICALLY TAKE MONTHS

Michener’s Executive Vice-President of Education Dr. Brian Hodges

is the education lead for the Toronto Region Critical Care Capacity Steering Committee, which asked Michener to bring together a task force to create the education resources.

That task force was chaired by Maria Tassone, Michener’s Senior Director of Continuing Education and Professional Development, and the education streams were led by Karen Chaiton, Director, Business Operations, and Mohammad Salhia, Director, Continuing Education and International.

They brought together not only an impressive team of subject matter experts from across the Toronto hospital and academic health sciences network, but also delivered Phase 1 of the education package and website within 10 days – a phenomenal accomplishment that would typically have taken months.

“This interprofessional and collaborative team has done a service of immense importance to healthcare pro-

fessionals from across the GTA who are now facing the very daunting prospect of working in critical care,” says Dr. Hodges.

“What this team has accomplished will directly translate into increased confidence and better peace of mind for very anxious healthcare professionals and I don’t think I am exaggerating when I say it will lead to better care for patients and contribute to lives saved.”

Within days of the site’s launch, more than 2,000 healthcare professionals accessed the site’s resources in order to prepare for possible redeployment.

Eden Wright, a registered nurse working in a cancer unit at Princess Margaret Cancer Centre that has recently transitioned to a COVID-19 unit, was one of the site’s early users.

“I can tell that working through the course will help my patients tremendously, as well as myself and my colleagues,” Eden says.

“Thanks again and know that this H will have a positive impact over here.” ■

SEPTEMBER 2020 HOSPITAL NEWS 25

ONLINE EDUCATION

Lessons on virtual care

from the COVID-19 pandemic n August 24, the Canadian Medical Protective Association (CMPA) hosted its first “virtual” Education Session titled Virtual Care in Canada: Lessons from the COVID-19 Pandemic.

O

The session focused on providing Canadian physicians with essential information on virtual care.

“The COVID-19 pandemic abruptly changed the healthcare landscape, and unexpectedly drove physicians and pa-

tients to widely adopt virtual care to a much greater degree than ever before,” says Dr. Lisa Calder, incoming CEO at the CMPA. “We know physicians are looking for guidance on how to manage this new practice landscape.”

In fact, since March of this year, the CMPA has received an unprecedented number of calls relating to virtual care. As use of virtual care continues to surge, it is crucial that physicians know how to leverage the opportuni-

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ONLINE EDUCATION

AS USE OF VIRTUAL CARE CONTINUES TO SURGE, IT IS CRUCIAL THAT PHYSICIANS KNOW HOW TO LEVERAGE THE OPPORTUNITIES OF VIRTUAL CARE AND ENSURE A SAFE VIRTUAL CARE EXPERIENCE FOR PATIENTS.

More specifically, physicians will want to use their professional judgment in assessing their ability to use virtual care, with regard to guidance from Colleges on how to provide care in the current context, and be mindful of the limitations of virtual care.

PRIVACY ties of virtual care and ensure a safe virtual care experience for patients.

“Virtual care is here to stay. Our next challenge is to safely integrate virtual with in-person care,” says Dr. Guylaine Lefebvre, Managing Director of Safe Medical Care at the CMPA and Moderator of the session. “The CMPA will continue to guide Canadian physicians as this hybrid model of medicine expands and evolves, and help them navigate issues of consent, privacy, and standards of care so that they can continue to provide the best care possible to patients across the country.”

The session, which featured digital health professionals, medical regulators, physicians, and medical-legal experts, provided advice on key issues in virtual care, including:

STANDARD OF CARE

Regulatory bodies have long established that the standard of care does not change when using virtual care.

However, the standard of care is evaluated in the context where care is provided. Should a patient require a more in-depth examination for diagnosis than can be provided virtually, generally the physician will be required to arrange this prior to providing treatment.

Virtual care can create additional privacy issues to which the physician must be attuned. The CMPA encourages physicians to follow privacy best practices. A physician’s duty of confidentiality and privacy obligations continue during the COVID-19 outbreak.

Patients should also be encouraged to take steps to participate in virtual care encounters in a private setting and using a personal device/computer and secured internet connection.

SUITABILITY

CONSENT

Physicians should assess the facts and circumstances and determine if a virtual visit is a suitable alternative to an in-person appointment. Sometimes virtual will be the best option and sometimes in-person will be required.

Physicians should obtain consent from their patient to use virtual care.

Such consent should be obtained following an informed consent discussion regarding the increased privacy risks associated with electronic communi-

cations as well as the limitations of the virtual context and documented in the patient chart.

THE FUTURE OF VIRTUAL CARE

It is safe to say that virtual care has rapidly become commonplace in the delivery of healthcare out of necessity. As physicians transition out of the pandemic and face-to-face appointments are possible, it is expected that virtual care will integrate into more of a hybrid model, driven by patient demand and convenience. Issues of consent, privacy, and standard of care will continue to prevail as some of the most important medical-legal considerations of the new model of medicine emerge from the pandemic.

Physicians with questions or concerns about virtual care are encouraged to contact the CMPA (1-800267-6522, www.cmpa-acpm.ca) for compassionate and informed advice.

Watch the CMPA education session The CMPA Education Session can be viewed in full at www.cmH pa-acpm.ca after September 8, 2020. ■

This article was provided by the Canadian Medical Protective Association.

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SEPTEMBER 2020 HOSPITAL NEWS 27

ONLINE EDUCATION

Exploring microaggressions in pediatric education and how everyone can play a role

By Ana Gajic patient is told their name is hard to pronounce. A doctor tells another doctor they speak English really well. While doing rounds, a resident is asked if she eats ‘strange foods’.

These are examples of microagressions – behaviours or remarks rooted in unconscious bias, which can be related to elements of a person’s identity such as race, gender, religion, sexuality or physical or intellectual ability. While the word suggests the act is small or subtle, their impact can be deep and lasting. For staff in a hospital setting, microagressions can impede learning, work and performance. They can also impact career decisions.

Three Toronto research scientists explored how microagressions affect medical students training to be pediatricians. Their commentary, published recently in Pediatrics, looked at what microagressions are, their presence in the learning environment, and opportunities for everyone to learn about how to stop them.

Here, we spoke to authors Dr. Shazeen Suleman, a Scientist at the Li Ka Shing Knowledge Institute and pediatrician at St. Michael’s Hospital; Kimberly Young, a senior medical student at the University of Toronto; and Dr. Angela Punnett, a pediatric oncologist at the Hospital for Sick Children (SickKids), about their analysis and why it’s important to help people spot microagressions when they happen – and how to respond.

A

WHY IS PEDIATRIC MEDICAL EDUCATION AN IMPORTANT AREA FOR LEARNERS AND TEACHERS TO CONSIDER THEIR OWN BIASES?

In pediatrics especially, all of our encounters include one very impressionable person: the child or youth patient themselves. If we are truly going to provide inclusive and supportive

care for our young patients, we must pay attention to the biases that we may inadvertently be telling them about themselves or others.

WHAT ARE SOME WAYS THAT DIFFERENT GROUPS CAN PREPARE FOR, RECOGNIZE, AND RESPOND TO MICROAGGRESSIONS?

It starts with each of us as individuals educating ourselves about racism, xenophobia and other forms of discrimination in our communities, both historical and current. We can take the initiative ourselves and as institutions, we can support formal educational initiatives to do this.

Second, we need to do a better job of listening to those who have experienced microaggressions. By their definition, microaggressions are often subtle and easily missed. Building caring communities where open conversations on difficult topics can be held is an important part of this. That same caring community should encourage individuals to recognize that making mistakes is part of growth, and it is how we respond and learn from these mistakes that is essential.

Third, and perhaps most important, we need to have organizations that represent the communities we serve.

As we write in our paper, it is impossible to respond to a transgression if you do not recognize it. By having people with lived experiences be represented in our institutions and communities, we can reduce microaggressions before they happen.

WHAT ADVICE WOULD YOU GIVE LEARNERS WHO ENCOUNTER MICROAGGRESSIONS IN THEIR LEARNING ENVIRONMENT?

First and foremost, we would say to the students directly we are sorry this has happened to you. We see and hear you. What you have experienced is real and your feelings - whatever they are - are extremely valid.

Secondly, what you have experienced is not okay, and we should not normalize it. We hope we can continue to increase the number of faculty and staff allies who can also be available to recognize, intervene in the moment and provide you with support. Please reach out to us if you need to! And most im-

portantly, we hope our work leads to fewer and fewer encounters like this.

WHAT DO YOU HOPE THAT PEOPLE WHO READ YOUR ARTICLE WILL COME AWAY WITH?

We really hope that readers, especially learners, will feel validated. We want them to be able to start to think about the moments where they felt uneasy and realize that was a real feeling and experience.

For educators reading this, we hope they also think about those same encounters and reflect on how a comment may have been hurtful, even if unintentional.

We hope people will realize that there is a way forward to address these, and it requires each of us as individuals to act, but also support one another as a community while building better and more inclusive institutions.

What do you hope for the future of pediatric medical education?

We hope that we develop pediatric health-care providers that are striving toward building a just and equitable society, within the clinic walls and H beyond. ■

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

28 HOSPITAL NEWS SEPTEMBER 2020

www.hospitalnews.com

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FROM THE CEO’S DESK

Lessons learned from the first wave

By Dr. Tim Rutledge

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IT WILL BE IMPORTANT TO DEVELOP LASTING SOLUTIONS TO ENABLE THE STABILIZATION AND RECOVERY OF THE LONG TERM CARE SYSTEM.

hat will the second wave be like? It’s a question we are all asking as we face the coming cold and flu

season.

Models can be helpful in predicting short-term scenarios, but with shifting public health policies and people’s behaviours, the next six to-eight months are too big a stretch to forecast with any certainty.

Will the next wave be like the first one, with exponential growth, a peak, then a gradual tapering off? Perhaps it will look more like a series of ripples, with various swells moving across the province at different times.

Layered on top are variables we didn’t face the first time around.

Schools, restaurants and bars are reopening. Winter is coming, drawing us indoors, and there will be the re-emergence of seasonal viruses that cause colds and flus.

Despite these uncertainties, we can be sure of a few things. The first wave has provided importantt lessons that will help us navigate what happens next.

WE ENTER THIS S NEXT PHASE KNOWING MORE RE ABOUT THE VIRUS RUS

While fears of airbornee transmission fueled anxiety over N955 mask availability in the early days off the pandemic, evidence and experience ence continue to indicate that the virus irus is mainly spread by droplets. Aerosol osol transmission may occur with aerosol-generating sol-generating medical procedures. This his supports our planning as we stock k up personal protective equipment in n preparation for the coming months.

We also know that a significant proportion of COVID-19 VID-19 transmission occurs before efore the onset of symptoms. This highlights why it’s critical ical to consistently practice the he basics of infection prevenn-

tion and control (IPAC): proper hand hygiene, physical distancing, mandatory masks and face shields for all patient interactions within six feet. Should a COVID-19 outbreak be detected, prompt testing of staff and patients should be carried out broadly, whether symptoms are present or not.

All of these IPAC practices do double-duty during flu season by reducing the spread of influenza and other seasonal viruses. Robust testing capacity and contact tracing will also be key success factors as the pandemic evolves and scientists race toward better treatments and a vaccine.

WE MUST OPTIMIZE SYSTEM CAPACITY

When COVID-19 struck, hospitals across Ontario braced for the surge that overwhelmed New York, Italy and China. An estimated 50,000 procedures and treatments were postponed in Ontario as the health care system took an all hands on deck approach to assuring the capacity needed for COVID-19 patients.

As clinical recovery plans continue in the face of this backlog, we must do all that we can to avoid a similar shutdown in the coming months. This will be a significant challenge as many hospitals had capacity pressures preCOVID, it will not be possible to be as efficient, and we have this new disease to accommodate.

Optimizing acute care capacity will require innovative and system solutions. Exponential increases in the use of virtual care have allowed people to connect with their providers from home avoiding hospital and clinic visits. Integrated models of care involving collaborations among primary care, home and community care and other community providers can help to avoid hospital admissions and shorten lengths of stay.

VULNERABLE POPULATIONS MUST BE A PRIORITY

The pandemic put p into stark relief some of the cracks in our ssystem.

About 80 per cent of c recorded deaths linked to COVID-19 in Canada C happened in long-term lon care, including more mor than Ontario.

1,800 deaths in O

A number of hospitals, including Unity Health Toronto, are now supporting seniors’ facilities and long term care homes with best practices for IPAC, health human resources and other areas. It will be important to develop lasting solutions to enable the stabilization and recovery of the long term care system.

Similarly, helping those who are experiencing homelessness and lack a safe place to isolate requires a holistic approach. Toronto and other jurisdictions have made use of hotel rooms to care for homeless and under-housed persons with COVID-19 or close contacts. In the coming months, as temperatures dip and indoor space becomes an even greater need, new models like these will be even more important.

TWO-WAY COMMUNICATION IS KEY

The flow of ideas keeps us all safe, and we must remain receptive to new approaches. Staff, physicians, patients and families need to be kept up to date with the latest information, while at the same time, feel encouraged to share their insights, concerns and ideas. At Unity Health, we increased the frequency of all our communications creating new virtual channels while engaging regularly with our Board and regional and provincial partners. We are also conducting an engagement pulse survey to hear from our staff and physicians where we can grow and learn from this unprecedented event together.

To a large extent, the shape and character of COVID-19’s second wave’s will be determined by public health policies and how well society adheres to them.

This pandemic has provided the healthcare sector an opportunity to accelerate change at an unprecedented rate. The importance of interdependencies of the sectors in our system have never been more clear. Working together in innovative ways will be key to managing successfully through the next phase of this pandemic and preparing for future H challenges. ■

Dr. Tim Rutledge is the President and CEO of Unity Health Toronto, the Catholic health network consisting of St. Joseph’s Health Centre, St. Michael’s Hospital and Providence Healthcare 30 HOSPITAL NEWS SEPTEMBER 2020

www.hospitalnews.com

EVIDENCE MATTERS

Managing severe symptoms of alcohol withdrawal:

The evidence on benzodiazepine alternatives

By Barbara Greenwood Dufour

t’s well known that longterm, excessive alcohol use is dangerous. But quitting drinking can be dangerous too. Alcohol withdrawal syndrome, which can occur when a

I

person with an alcohol dependence disorder suddenly stops drinking, can be an emergency situation.

In the first hours after the last drink, symptoms may be unpleasant but manageable (e.g., nausea, agita-

tion, trouble sleeping) but, after three or four days, symptoms can become much more severe and may include seizures and delirium tremens – severe confusion, fever, drenching sweats, hallucinations, marked tremulous-

ness (the “shakes”), severe hypertension (elevated blood pressure), and tachycardia (rapid heart rate). These symptoms require medical treatment, as they are potentially fatal.

Continued on page 38

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SEPTEMBER 2020 HOSPITAL NEWS 31

LONG-TERM CARE NEWS

Elder care reform

must start with skills training

By Sarah Watts-Rynard hen it comes to tragedy, the human instinct is to assign blame. In the case of pandemic-induced deaths in Canada’s long-term care facilities, there are no end of culprits: governments for regulatory and oversight failures, owners and managers for poor employment practices, workers for abandoning their posts.

Regardless of the direction the finger is pointing, the reality is that the senior population is growing, the cost of high-quality elder care is sky-rocketing and demographics dictate that the need for long-term care is here to stay.

Part of the solution starts with a highly skilled workforce that can rely on well-developed training pathways both before and throughout their careers.

Elder care is a segment of the healthcare system few want to think about. Most Canadians put off longterm care for their aging relatives until health, mobility and/or cognitive issues make it necessary. Even then, family becomes an integral part of the care-taking team in sometimes crowded and often understaffed conditions.

The situation in many long-term care homes was ripe for a COVID-19 wakeup call.

Responding to that call requires a new cross-country emphasis on high-quality applied learning that combines knowledge and know-how, incorporating concrete training on subjects like sanitation, food safety and infection prevention with human skills such as empathy, patience and optimism.

Today, an unregulated workforce provides as much as 80 per cent of direct care to nursing home residents and there is no national standard for training. According to 2018-19 data collected by the Canadian Institute of Health Information, more than 54 per cent of the population in long-term

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IT IS TIME FOR REGULATORS TO MAKE QUALITY TRAINING MANDATORY ACROSS THE FULL SPECTRUM OF HEALTHCARE PROFESSIONS, INCLUDING LONG-TERM CARE. care is over the age of 85, 44 per cent have reduced physical function and more than 80 per cent suffer moderate to severe cognitive loss. This reality suggests it is not merely a matter of deploying more people to work in longterm care or calling in the military to offer emergency support. Rather, the appropriate response is one that ensures the workforce is well-equipped for roles that are both physically and mentally demanding.

This is a space where Canada’s polytechnics are ahead of the curve, offering everything from entry-level training to professional development and applied research in the elder care sector. It is time to make high-quality training a requirement of occupations in long-term care.

As in all healthcare occupations, theory-based training alone is not sufficient. Polytechnic elder care programs are heavily weighted toward hands-on, practical training and simulation. High-tech laboratories have been set up to simulate a variety of long-term care settings – from hospital-style wards to private rooms and apartments. Walking into one of these spaces feels like a visit with your grandmother.

Real-life scenarios are built into the polytechnic training environment, with situations that draw learners into the realities of working with physically and cognitively impaired adults.

Learners are required to wear personal protective gear and are tasked to interact with high-tech mannequins that

speak, breathe and can be programmed to simulate very human scenarios.

This approach embraces the technology and equipment of the modern healthcare sector, but goes further, focusing on how to support human beings.

But even realistic scenario-driven teaching cannot fully capture the skills development process. A large majority of polytechnic programs include a work placement as a mandatory requirement of graduation. Elder care students need opportunities to put their skills into practice, building both competence and confidence.

In other words, a well-prepared and highly trained workforce is no simple matter.

It is time for regulators to make quality training mandatory across the full spectrum of healthcare professions, including long-term care. While the COVID-19 pandemic shines a light on understaffed and overwhelmed conditions in some of Canada’s longterm care homes, considerations and solutions must build on what we know works. Well-trained, well-compensated and well-supported healthcare workers are better able to respond to the demands of a stressful work environment. The elderly population deserves nothing less.

But polytechnics can’t do it alone.

Solutions must include new investments from governments in hands-on learning for the long-term care sector.

It is critical to get learners back to the classroom, safely, during COVID-19. This may well require that institutions rethink class sizes, scheduling, space utilization and cleaning processes. There’s also the need for improved training equipment and spaces that often go too long between upgrades.

Realistically, none of this comes without a cost.

Equally, long-term care homes must

Sarah Watts-Rynard is CEO of Polytechnics Canada, a national association of the country’s leading polytechnic institutions. Polytechnic education is industry-driven and hands-on, actively preparing graduates for the world of work.

32 HOSPITAL NEWS SEPTEMBER 2020

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LONG-TERM CARE NEWS

be supported in their efforts to provide supervised, professional clinical placements. Elder care – a field dominated by women – tends to rely on unpaid work terms. In Budget 2019, the federal government invested $798.2 million over five years in work-integrated learning, but little of it will flow to placements in the “caring economy.”

The pandemic serves to draw new attention to this oversight.

Finally, initial training and ongoing professional development should be required across the sector for workers in both private and public long-term care facilities. Given the very real stresses of the job, quality care for seniors relies on our capacity to support frontline workers. This will undoubtedly require a new approach to funding high-quality long-term care.

The time for blame has long passed.

The opportunity for action lays ahead.

Let’s not miss the chance to do it right, particularly given that long-term care may well be something many of will experience firsthand at some point in H the future. ■

Long-term care staffing study he Registered Nurses’ Association of Ontario (RNAO) says the longterm care (LTC) staffing study released by the government highlights deficiencies known for decades. The government’s Long-Term Care Staffing Study Report provides recommendations within five priority areas to improve staffing across the sector: 1. The number of staff working in long-term care needs to increase and more funding will be required to achieve that goal 2. The culture of long-term care needs to change – at both the system and individual home level 3. Workload and working conditions must get better, to retain staff and improve the conditions for care 4. Excellence in long-term care requires effective leadership and access to specialized expertise

T

5. Attract and prepare the right people for employment in long-term care, and provide opportunities for learning and growth The need for immediate action is outlined in RNAO’s Nursing Home Basic Care Guarantee submission to the government’s Long-Term Care Staffing Study Advisory Group, which was struck by minister Fullerton in response to the public inquiry on LTC homes, which issued its recommendations on July 31, 2019. Justice Eileen Gillese led that inquiry and gave the government a deadline of July 31, 2020 to table in the legislature a staffing plan for regulated staffing in LTC. The government’s report highlights a minimum staffing complement to provide four (4) direct hours of nursing and personal care per resident, per day. However, the report fails to specify the skill-mix composition of those four hours, leaving residents, families and staff to the will of operators.

RNAO will continue to call for the Nursing Home Basic Care Guarantee as the only way forward. It will also continue to urge that no nursing home – whether for-profit or not-for-profit – go below four hours of direct nursing and personal care per resident, per 24 hours. All homes must guarantee a proper skill mix as follows: • 0.8 hours (48 minutes) of RN care per resident, per 24 hours • 1 hour (60 minutes) of RPN care per resident, per 24 hours • 2.2 hours (132 minutes) of PSW care per resident, per 24 hours RNAO is also calling on government to fund each LTC home for one NP per 120 residents, in the role of attending NP or director of clinical care; as well as one additional nursing full–time equivalent (FTE) staff (preferably an RN) to support the functions of infection prevention and control and quality H improvement. ■

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www.tenaprofessionals.ca SEPTEMBER 2020 HOSPITAL NEWS 33

LONG-TERM CARE NEWS

â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s about the person, not the dementiaâ&#x20AC;?â&#x20AC;&#x201C;

Bringing person-centred care to life

By Arielle Townsend n his book, Dementia Reconsidered: The Person Comes First (1997), Professor Thomas Kitwood defines personhood as, â&#x20AC;&#x153;A standing or status that is bestowed upon one human being by others, in the context of relationship and social being. It implies recognition, respect, and trust.â&#x20AC;?

More than 23 years later, Kitwoodâ&#x20AC;&#x2122;s definition continues to shape person-centred care, and has formed the basis for the Personhood Kit Project, being developed by New Brunswick long-term care facility Loch Lomond Villa, with support from the Centre for Aging and Brain Health Innovationâ&#x20AC;&#x2122;s (CABHI) Spark Program.

Person-centred care recognizes the inherent value and dignity of human life. Kitwood was the first to expand the term to dementia care, highlight-

I

ing that every life, regardless of cognitive and physical ability, should be guarded as sacred and unique.

When practiced, person-centred care can help caregivers provide effective, personalized support to their clients, instead of the traditional onesize-fits-all medical approach.

As dementia progresses, verbal communication and memory recall decreases â&#x20AC;&#x201C; reducing a personâ&#x20AC;&#x2122;s ability to assert their needs, interests, and values. The Personhood Kit Project, launched in 2017, acts as a portal into the lives of those living with dementia, helping them to tell the world who they are and what aspects of their lived experiences make them unique.

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The kit is comprised of four key components: family, hobbies, attri-

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butes, and occupation. Items in the kit can include things like an instrument the resident enjoys playing, or memorabilia from their careers. Together, the items tell a story of the residentâ&#x20AC;&#x2122;s values, interests, and identity. Staff can use the kit to get to know residents better or engage them in meaningful face-to-face interaction. As a result, care can shift from a task-oriented to relationship-based approach, says Shelley Shillington, Director of Operations at Loch Lomond Villa and the Personhood Kit Project lead. â&#x20AC;&#x153;Human beings are made for relationships,â&#x20AC;? says Shillington. â&#x20AC;&#x153;To build a relationship with a person living with dementia, you have to understand their story.â&#x20AC;?

After launching the project, Shillington noticed the kits were improving

the residentsâ&#x20AC;&#x2122; overall moods and levels of engagement â&#x20AC;&#x201C; an indication of heightened well-being. â&#x20AC;&#x153;There was one lady who was a great horticulturist,â&#x20AC;? says Shillington. â&#x20AC;&#x153;We would have pots and she would make her arrangements with plastic flowers. She would focus on the task and actually complete it, whereas before she wouldnâ&#x20AC;&#x2122;t really engage in activity time.â&#x20AC;?

Family members can add information and materials to the kits, which creates an opportunity for them to support their loved onesâ&#x20AC;&#x2122; care, even when they are not physically present.

SEEING BEYOND DEMENTIA

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LONG-TERM CARE NEWS sociated with dementia, such as agitation or resistance.

“People’s stories are so important to who they are,” says Jillian Higgins, Recreation Therapist at Loch Lomond Villa. “When a resident is having difficulty receiving care, you can look at their bio and say, well maybe they’re having a hard time because of something they told us here. It gives you a different perspective on the behaviour they’re showing you.”

“It changes your whole approach,” Shillington adds. “Instead of seeing a person with dementia, you see Cyril who loves music and enjoys organizing things.”

Shillington and her research team began the project with a goal of engaging 25 residents from their Cedar House, a portion of the Loch Lomond facility that specializes in dementia care. Now she seeks to engage any resident that would gain from participating in the program.

“We’ve built a procedure to keep this program going and can make the

content specific to more residents who would potentially benefit from the Personhood Kit.”

With a focus on advancing quality, person-centred dementia care, Shillington and her team are

poised to make a difference in the lives of older adults for years to H come. ■

Arielle Townsend is the Marketing & Communications Specialist at the Centre for Aging & Brain Health Innovation.

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SEPTEMBER 2020 HOSPITAL NEWS 35

LONG-TERM CARE NEWS

Bridging the distance

for caregivers dealing with dementia

By Monica Fleck he onslaught of the COVID-19 pandemic struck nearly every aspect of life with a quick and stunning blow. Within the fallout, particularly for our more vulnerable senior population, lay a particularly impacted segment – those who are caring for someone with dementia at home.

No longer available were the adult day programs, where caregivers would send their loved ones for quality programming and respite for themselves, nor the standard in-person services, such as support groups, overnight respite, or on-site counselling.

“We saw an immediate and urgent need to help caregivers in their important roles at home,” says Karen Johnson, director of McCormick Dementia Services in London, Ontario.

“We pulled together all our available staff resources to find ways to help people meet the challenges presented by the pandemic, and relied heavily on our creative and technological skills.”

Caregivers often find themselves confronted by the constant demands of caring for their loved ones, who can often be in a high-needs category. They may face challenges helping the person with meals, bathing, providing personal care, and seeking outlets for entertainment and meaningful engagement, all while keeping the person safe.

In response, McCormick Dementia Services, home to Ontario’s largest dementia-specific day program, began to quickly develop several virtual resources to help caregivers in their important role. While social work support delivered one-on-one by phone was already available, staff also wanted to teach caregivers a number of different strategies on how to provide the various types of care required. The solution was to develop the Caregiver’s Corner website, which contains a variety of presentations and videos delivered by care

T

support and recreation staff members that address personal care, recreation activities, and strategies for managing day-to-day tasks.

“The site marked a significant step toward empowering caregivers with the knowledge of what to do and how to do it,” says Johnson.

For example, the nursing and personal care portion of the site contains detailed instructional videos on how to dress someone with dementia, how to respectfully administer medications if the person is reluctant, and how to prepare and serve different types of food for a pleasant and safe dining experience. In addition, the recreational section of the website has a wide choice of games, puzzles, exercises and modules on many general-interest topics, such as music, celebrities, countries and national holidays.

“I realized while being at home with my mom that she was no longer capable of just tagging along with what I was doing or a version of it, so I’ve found that I have to plan specific things to do with her,” says

Irene*, a caregiver whose mother regularly attended the McCormick Day Program. “I have so far used the Caregiver Tips section, which I found very helpful, particularly understanding behaviours, as well as the daily schedule, which has been most useful. There is a lot on the site; it is very well organized. We haven’t explored even half of it yet, but we will!”

Technology has also enabled McCormick Dementia Services to offer connectedness through support groups, exercises classes and social time delivered via Zoom videoconferencing.

“Often, the best assistance we can provide is to connect caregivers with each other to remind them that they are not alone in this journey,” says Johnson.

“Group members often provide a tremendous lift in spirits and much-needed friendship. Another thing we have discovered is the positive impact our Zoom programs are having on our clients; they are loving it, and caregivers are grateful that their loved one is engaged in something fun.”

Facebook has also become an ideal way to support caregivers.

In May, McCormick Dementia Services began offering livestream sessions twice a week that highlight staff and programming updates, art therapy instruction, crossword and trivia clubs, ideas for outdoor games and activities, strategies for keeping wandering people safe and tips on managing responsive behaviours.

“One of our caregivers called to tell us how he has been watching our videos,” says Johnson. “He said that the one on tips and tricks to provide care was very helpful when toileting his mom. He was very thankful.”

“I want to thank the staff for all the hard work that went into this outreach,” says Irene. “It is truly a wonderful resource, and is saving my sanity right now!” *Please note that names have been changed for privacy reasons. For more information, please visit mccormickH dementiaservices.ca. ■

Monica Fleck works in communications at McCormick Care Group.

36 HOSPITAL NEWS SEPTEMBER 2020

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LONG-TERM CARE NEWS Continued from page 31

Managing severe symptoms of alcohol withdrawal Symptoms of alcohol withdrawal syndrome are typically managed in a hospital setting using benzodiazepines (e.g., diazepam, chlordiazepoxide).

Benzodiazepines are central nervous system depressants that are also used to treat anxiety, insomnia, and seizures. They can cause severe side effects, such as respiratory depression, especially when high doses are needed to get alcohol withdrawal symptoms under control. Therefore, other drugs – including phenobarbital and gabapentin – have been suggested for use instead of, or in combination with, benzodiazepines.

To get a sense of how these other potential treatment options compare with benzodiazepines, CADTH – an

independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – looked for recent research and evidence-based guidelines on this topic. Then, to balance timeliness with rigour, CADTH prepared a summary of the abstracts – this means CADTH reviewed only the abstracts and didn’t critically appraise the literature (read more about the types of Rapid Response reports CADTH produces at cadth.ca/ about-cadth/what-we-do/products-services/rapid-response-service).

Phenobarbital is a barbiturate (another type of central nervous system depressant) – commonly used to treat insomnia, headaches, and seizures.

The existing research suggests it might

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be an option for alcohol withdrawal syndrome, at least when used in addition to benzodiazepines. CADTH found two systematic reviews and seven non-randomized controlled studies comparing phenobarbital with benzodiazepines. In most of these studies, including both of the systematic reviews, phenobarbital alone or added to benzodiazepine treatment led to similar outcomes to benzodiazepines alone – including admission to the intensive care unit (ICU), length of time in the ICU or hospital, tolerability and safety profiles in the acute care setting, and improvement in severity and duration of alcohol withdrawal symptoms. In two of the non-randomized controlled trials, phenobarbital (on its own in one study and along with benzodiazepines in the other) led to more favorable outcomes, namely shorter ICU and hospital stays, than benzodiazepines alone.

Gabapentin, an anti-seizure drug, is another potential treatment for alcohol withdrawal. CADTH found three non-randomized studies comparing combination gabapentin and benzodiazepine therapy with benzodiazepines alone. According to two of these studies, patients on combination therapy had similar outcomes to those treated only with benzodiazepines in terms of the severity of their withdrawal symptoms, how long they were on an alcohol withdrawal protocol, and the length of their hospital stay. In the third study, patients on combination therapy had significantly reduced alcohol withdrawal symptoms on day three of hospitalization and a shorter length of hospital stay compared with those who received only benzodiazepines.

CADTH found four related evidence-based guidelines, all of which recommend benzodiazepines for managing alcohol withdrawal in the emergency department, and two of which suggest alternate treatments as well.

The British Columbia Centre on Substance Abuse recommends in-patient administration of benzodiazepines for patients at a high risk of alcohol withdrawal. The Canadian Coalition of Seniors’ Mental Health recommends that older adults receive in-patient treatment with a short-acting benzodiazepine, such as lorazepam, which is safer in this population. The guideline from the National Institute for Health

and Care Excellence in the UK recommends that acute alcohol withdrawal be treated in a hospital setting using a symptom-triggered regimen (providing medication only when a patient is having symptoms) of benzodiazepines, carbamazepine (an anticonvulsant), or clomethiazole (a sedative). And the US Department of Veteran Affairs and Department of Defense recommends treating moderate to severe alcohol withdrawal with a symptom-triggered regimen of benzodiazepines. They also recommend gabapentin, carbamazepine, or valproic acid (another anti-seizure drug), but only for patients with mild to moderate alcohol withdrawal for whom the risks associated with benzodiazepines outweigh the benefits.

The abuse, overdose, and diversion potential associated with benzodiazepines means they’re best administered in an in-patient setting. But treatment that could be safely provided on an outpatient basis could improve access to treatment and be a preferable option for those who are reluctant to be treated in a hospital – such as during the current COVID-19 pandemic when there may be concern about in-patient exposure to coronavirus.

Phenobarbital and gabapentin, because they are considered to be safer than benzodiazepines, could potentially be given in an outpatient setting.

But, it’s yet unclear how effective they are on their own for managing alcohol withdrawal syndrome.

Instead, the research appears to suggest that phenobarbital and gabapentin, when used in combination with benzodiazepines, might be a way to make in-patient treatment for alcohol withdrawal syndrome safer than treatment with benzodiazepines alone.

Further analysis of the latest evidence would be needed, however, to make conclusions or suggest what the implications of this research might be for health care decision-making.

View CADTH’s full report at cadth.ca/gabapentin-phenobarbital-diazepam-and-lorazepam-treatment-alcohol-withdrawal-clinical-effectiveness. If you’d like to learn more about CADTH, visit cadth. ca, follow us on Twitter @CADTH_ ACMTS, or speak to the CADTH Liaison Officer in your region: cadth.

H ca/liaison-officers. ■

Barbara Greenwood Dufour is a knowledge mobilization officer at CADTH. www.hospitalnews.com

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