Hospital News August 2019

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

Paediatrics

August 2019 Edition

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Contents August 2019 Edition

IN THIS ISSUE:

Concussion rates are nearly double

5 ▲ Cover story: Working together to save kids

26 COLUMNS Guest Editorial .................4 ...6 In brief .............................6 .12 Evidence matters ...........12

▲ Helping patients with Parkinson’s walk again

8 ▲ Smooth transition from hospital to home

▲ Medical social workers play a vital role

15

22

.14 From the CEO’s desk .....14 .16 Ethics .............................16 .18 Nursing pulse ................18 .30 Long-term care ...............30 .36 Safe medication ............36

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Suppo Supporting o residents’ h through sound mental health

34

Measuring what matters in hospitals

By Anna Greenberg and Anthony Dale allway health care – gurneys with sick patients lining hospital corridors – is one of the most graphic representations of the pressures on Ontario’s health system today. We know that the equivalent of more than 10 large, 400-bed hospitals are filled to capacity each day by patients who don’t need the level of services hospitals are designed to provide. They are waiting for more appropriate placement in long-term care, rehabilitation, home care and assisted living.

Tackling these and other system challenges requires an accurate assessment of their scope and scale. Every health care system needs to measure how it is doing so it can improve and so Ontarians know whether the system is moving in the right direction and if they are getting good value for their money.

To properly support the priorities for the system, it is important that what we measure helps us identify and focus our efforts on the most pressing concerns.

It is also important not to overwhelm health care professionals with a burdensome requirement to measure too much. As health quality guru Dr. Don Berwick wrote in 2016, excessive and mandatory measurement “is as unwise and irresponsible as is intemperate health care”. Measurement should provide meaningful information on performance, so providers can begin the quality improvement process, if required.

The Ontario Hospital Association and Health Quality Ontario are working together to stop excessive

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measurement and prioritize what matters. The objective is to ensure that investment and efforts to measure and report performance indicators in hospitals support better patient outcomes and are aligned with Ontario’s health system strategy.

Depending on the size and type of institution, senior leaders in hospitals in Ontario have identified more than 300 indicators that cross their desks from different organizations, in different report formats, on different time cycles and sometimes with overlapping indicators using different definitions. This is in addition to what a hospital may choose to collect on their own to manage and improve care and operations.

Some of these quality improvement indicators are duplicative or not aligned with one another. Additionally, hospitals are asked to individually calculate and submit indicators when they might be more efficiently monitored centrally.

When we asked hospital leaders what was useful in all this reporting for managing and improving quality, the number of indicators shrunk by about a third. This didn’t mean that there weren’t gaps (e.g. what truly matters to patients), but it did highlight that there was a lot of measurement and reporting happening that was clearly of low value.

One of the key issues we identified is that our system tends to add new measures but is reluctant to retire measures even when they are not actively being used to make decisions or improvements.

Continued on page 6

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NEWS

Concussion rates are nearly double what we thought

By Ellen Rosenberg ith concussions seeming more common than ever before, researchers at Toronto Rehabilitation Institute – University Health Network, set out to answer the question, “Are we looking at a true epidemic, or just better recognition?�

By embarking on the largest-scale study on concussions ever undertaken in Canada, the researchers discovered that 150,000 Ontarians (1.2 per cent of the province’s population) are diagnosed with a concussion each year.

That’s almost twice as high as previously recorded, and may represent a closer estimate of the true picture of concussion in Ontario.

Their findings were published in the Journal of Head Trauma Rehabilitation. “Past research has looked at the incidence of concussion by examining a particular population; cause of injury; or used a single reporting source, such as records from the Emergency Department. This can under-represent estimates of the real incidence of concussion,� says Laura Langer, Research Analyst and Lead Author. “Our study revealed concussion rates that are almost double what has been previously reported, and highlights the critical importance of looking at everyone who sought medical attention for their concussion.�

These more accurate estimates support the importance of ongoing awareness around concussion symptoms and management, and the need for more specialized concussion clinics near populations that need them the most.

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CONCUSSIONS IN ONTARIO – WHO IS AT RISK? By leveraging the ICES Data Repository – a province-wide archive that integrates multiple clinical and administrative health databases – the team captured an unprecedented, comprehensive, view of concussion rates in Ontario between 2008 and 2016. www.hospitalnews.com

The study, conducted by Dr. Mark Bayley (left), lead author Laura Langer (centre), and Charissa Levy (right) supports the importance of ongoing awareness around concussion symptoms and management, and the need for more specialized concussion clinics near populations that need them the most.

Here is what they found: • About 150,000 Ontarians experience a concussion each year • Children under five experience the highest rate of concussion among all Ontarians • Adults over 65 – especially women – experience a higher rate of concussion than younger adults • 26 per cent of all concussions are diagnosed in the summer • Rural communities experience a higher rate of concussion than non-rural communities • Though most concussions are diagnosed in the Emergency Department, more and more patients with concussion symptoms are visiting their own doctors

EPIDEMIC OR BETTER RECOGNITION? According to the team, the high rate of reported concussions is likely influenced by a number of factors, including increased public awareness from athletes and the media, new mandatory reporting laws, and the

release of numerous diagnostic and management guidelines for physicians and patients.

FUTURE DIRECTIONS As an increasing number of patients are visiting their doctors when they experience a concussion, it’s more important than ever to educate primary

care physicians on concussion symptoms and management.

Furthermore, these findings can be vital for helping to inform future healthcare planning: Now that we’re able to identify who is at greatest risk, and where they live, we have an opportunity to ensure that high-risk patients have access to specialized conH cussion clinics. â–

Ellen Rosenberg works in communications at University Health Network.

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IN BRIEF

Measuring what matters in hospitals

Surgery before pregnancy

Continued from page 4 We don’t have clear criteria for when a measure should be modified or retired. And even when we add measures, we don’t always have a clear plan for how that data will be used. In the worst cases, there is data being collected routinely and no one is using it or looking at it.

Working closely with senior hospital and system leaders we have committed to: 1. Significantly reduce what we currently measure in hospitals, retiring measures of little to no value; 2. Revisit what we measure on a routine basis (i.e. annually) to make sure it continues to be of value; 3. Exercise much more discipline when we add measures about the plan for how it will be used; 4. Distinguish between what is important enough to be publicly reported vs. what is a lower priority but should still be monitored vs. what is low value and should be retired.

5. Recommending a centralized system where indicator performance is monitored and communicated back to providers or stakeholders when an issue has been identified.

An emphasis on a smaller number of system measures necessarily requires more discipline. It forces us to make important choices at the individual hospital and system levels, and it acknowledges that improvement can happen with the right focus. The hard work of quality improvement is not measurement. It’s the incremental and iterative steps frontline health care professionals and teams take to make patient care better. Measurement is vital to knowing whether these improvements make a difference. But excessive measurement can be a needless distraction from the hard work of improvement.

Measurement has always been a critical part of the delivery of quality care and as Ontario embarks on a restructuring of care delivery, it is clear the province’s hospitals need to be well-aligned to measure what H matters. ■

abies whose mothers underwent surgery before pregnancy had an increased risk of opioid withdrawal symptoms at birth, found a new study in CMAJ (Canadian Medical Association Journal).

“Use of opioids for pain control after surgery may increase the risk of opioid dependence in women and withdrawal in their newborns,” says lead author Dr. Nathalie Auger, University of Montreal Hospital Research Centre, University of Montreal and McGill University. “We found mothers who had surgery before pregnancy had 1.6 times the risk of neonatal abstinence syndrome; that is, opioid withdrawal symptoms in their future newborns, perhaps because opioid use continues after surgery.”

The large study included data on almost 2.2 million births in Quebec between 1989 and 2016. Of the total, 2346 newborns had neonatal absti-

6 HOSPITAL NEWS AUGUST 2019

linked to increased risk of opioid withdrawal in babies

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MOTHERS WHO HAD SURGERY BEFORE PREGNANCY HAD 1.6 TIMES THE RISK OF NEONATAL ABSTINENCE SYNDROME nence syndrome and, of these, 1052 had mothers who underwent pre-pregnancy surgery (14.9 per 10 000 babies) compared with 1294 babies (8.8 per 10 000) born to mothers who did not have surgery. Multiple surgeries; younger age at surgery; longer time between surgery and pregnancy; and cardiovascular, thoracic, urologic, or neurosurgery were associated with the largest risk of neonatal abstinence syndrome. There was also a strong association with general anesthesia, perhaps

because this type of anesthesia is used in more complex surgeries, which can require longer use and higher dosage of pain relievers.

“Physicians have the potential to prevent neonatal abstinence syndrome with careful postoperative pain management in young women,” says Dr. Auger. “Opioids continue to be overprescribed, despite calls to optimize postsurgical pain control through improvement of surgical guidelines and use of multipronged approaches with nonopioid painkillers or local anesthetics,” she says.

Limiting postoperative opioid exposure, reducing overprescribing and screening for opioid use in pregnant women who have had previous surgery may help reduce the risk of neonatal abstinence syndrome.

“Maternal prepregnancy surgery and risk of neonatal abstinence syndrome in future newborns: a longitudinal cohort H study” was published July 15, 2019. ■

Innovative program improves patient access to specialist medical advice in primary care across Canada he Canadian Foundation for Healthcare Improvement (CFHI), in partnership with Canada Health Infoway, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada, has announced the successful expansion of provider-to-provider remote consult services, improving patient access to specialist advice in primary care in seven provinces.

Through the 18-month Connected Medicine: Enhancing Primary Access to Specialist Consult collaboration, primary care providers initiated more than 12,300 remote consults with specialists to support patient care. Teams from Newfoundland and Labrador, New Brunswick, Quebec, Manitoba, Saskatchewan, Alberta, British Columbia, and the Department of National Defense, enrolled more than 2,200 primary care practitioners and

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800 specialists, including many in underserved rural and remote regions.

These practitioners can now access specialist consults through secure digital technology and telephone services.

The result is that eligible patients get care based on specialist advice closer to home, by a primary care provider they know and trust. The process is typically faster than being referred for a face-to-face specialist appointment and often avoids unnecessary trips to the emergency department.

CONNECTED MEDICINE RESULTS: • Rapid access to specialist advice: More than 4 in 5 eConsults (85 per cent) received a response from a specialist within 7 days (based on a sample of more than 3,200 eConsults). This work addresses a recognized issue in Canada, for example, as identified in the 2016 Common-

wealth Fund Survey, where Canada placed last on a measure of specialist access among the 11 countries surveyed, with 56 per cent of Canadians reporting waiting four weeks or longer to see a specialist.

• Care Closer to Home: More than half of eConsults (53 per cent) led to an appropriately avoided face-toface referral to a specialist, where one was originally contemplated but no longer needed based on specialist advice (based on a sample of over 2,600 e-consults).

• Avoided ED Visits: 2 in 5 remote consults (42 per cent) via phone/ app led to an appropriately avoided emergency department (ED) visit, where the primary care provider originally contemplated sending the patient to the ED but the visit was no longer needed based on specialist advice (based on a sample of over H 600 phone or mobile app consults). ■ www.hospitalnews.com

NEWS

A modern cancer plan to reduce care inequities

By Cynthia Morton wo years ago, I was approached by an organization called the Canadian Partnership Against Cancer asking me to join as CEO. I was six months past a challenging two and a half years of intense cancer treatment including chemotherapy and radiation therapy.

My recovery was difficult, and I was ready to take on another leadership role. The Partnership was one I knew would inspire me personally and professionally. I know firsthand the toll cancer takes on patients, their family and friends. As a patient, I benefitted from the many strengths of Canada’s cancer system.

I was treated blocks away from where I live and work, and I received regular care from a knowledgeable family physician.

This is not the cancer story for all Canadians.

As we consulted with people across the country last year on the creation of a modernized cancer control strategy, I was struck by the affirmation of a shared view that it should not matter where you live in Canada or how much money you make, we are all entitled to accessible, quality cancer care. This is a fundamental belief of Canadians and distinguishes us as a nation in a profound way resulting from our health system being grounded in a value of universal health care. The challenge is that while people in certain parts of the country have cancer care like mine, many do not. The reality is that where you live and other factors like employment can be a matter of life and death when it comes to cancer, and as a country we can and must do better.

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ACCORDING TO THE CCS, ONE IN TWO CANADIANS WILL BE DIAGNOSED WITH CANCER IN THEIR LIFETIME. In June my organization released the 2019 Canadian Strategy for Cancer Control for the next decade. This is Canada’s cancer plan which provides a focused set of priorities and actions that we’ve shaped with our many partners to combat the complexity

and overwhelming impact of cancer.

My organization is the steward of the Strategy and at the request of the federal government, we engaged over 7,500 Canadians, healthcare providers and cancer care leaders to help in modernizing this plan, ensuring that it provides concrete, shared direction supported by provinces and territories, to address the challenges in delivering quality cancer care to people in all parts of the country.

Importantly, the modernized Strategy also contains priorities to solve barriers faced by First Nations, Inuit and Métis in accessing timely and culturally appropriate cancer care. Indigenous peoples in Canada continue to experience poorer cancer outcomes than the rest of the population, and the Strategy offers solutions developed with First Nations, Inuit and Métis communities, governments, elders and organizations.

Through the development of this Strategy with our many partners, we have explored the depth of inequities that exist in cancer services across the

country and actions we must take to address these. We must learn from the best so all in Canada can benefit from what is working, while keeping an eye on the financial viability of new approaches to delivering cancer care. We must push for more patient-centric care learning more about who our patients are, and what they value or fear, when discussing cancer with their doctor, and acknowledging and addressing the presence of cultural incompetency in cancer care for certain groups.

We must embrace innovation and use technology to better connect with remotely located patients who will otherwise face hours, if not days, of painful and disruptive travel to get the care they need.

We have many willing partners in the cancer community across Canada who are up to the task and ask that healthcare providers and leaders who we haven’t engaged with, take note of the priorities and calls to action in the Strategy, and work with us and others to make change happen. We ask that all Canadians look for ways to get involved with their local cancer organizations, and read the 2019 Strategy at www.cancerstrategy.ca. According to the Canadian Cancer Society, one in two Canadians will be diagnosed with cancer in their lifetime. I’m part of this statistic and believe that together we can use this cancer plan to guide efforts in getting high-quality cancer services and improved cancer prevention knowledge to every corner of the H country in the next 10 years. Q

Cynthia Morton is the CEO of the Canadian Partnership Against Cancer www.hospitalnews.com

AUGUST 2019 HOSPITAL NEWS 7

NEWS

Revolutionary research helping patients with Parkinson’s walk again

By Laura Goncalves or patients living with Parkinson’s disease, it is common to develop significant motor symptoms especially as the disease progresses. Many experience issues with walking, freezing and instability.

This can cause people to have difficulties walking to the point of needing assistance, including being bound to walkers and wheelchairs or motorized devices, and those who are housebound and even bedridden the majority of the time. For many, they are simply unable to walk steadily without assistance which can greatly impact their everyday life.

These symptoms are largely resistant to the common dopamine replacement therapy. The benefits of deep brain stimulation have proven to be limited and unpredictable, and this option is only available to a fraction of patients.

“Introducing a novel therapeutic intervention is a significant unmet need for patients with Parkinson’s who don’t have other treatment options,” explains Dr. Mandar Jog, Assistant Director at Lawson Health Research Institute and Professor at Western University.

He is the lead for a research team in London, Ontario that is the first in the world to successfully trial an implant in the spine that boosts the signals between the body, spinal cord and brain. They have shown that supporting the signals moving from the body towards the brain can greatly improve movement and stop the freezing as patients walk.

Dr. Andrew Parrent, Neurosurgeon at London Health Sciences Centre, collaborates with Dr. Mandar Jog on this research and implants the devices into the research participant’s spinal cord. “A wire is threaded in the dorsal area of the spine and attached to the stimulator implanted in the body.”

The stimulator is rechargeable for up to 15 years and comes with a re-

The stimulator comes with a remote control and is rechargeable for up to 15 years.

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Brain scans showed that before patients received the electrical treatment, the areas that control movement were not working properly. But a few months into the treatment those areas were restored. mote control. “They can easily turn the electrical signal on or off, and dial the strength up or down,” explains Dr. Parrent. The research team programs the device for each individual patient

and is monitoring the results over time.

“We’ve previously seen progress in the therapeutic use of spinal cord stimulation and didn’t know if we would see any improvement for our patients.

The results have been astonishing – with patients who previously could not walk independently now making tremendous advances,” says Dr. Jog. “The best part is that their confidence levels have gone up. They can get back to doing the things in life that many of us take for granted, like taking a walk in the park or going on vacation.”

Dr. Jog sees potential for this to be routinely used as an effective and cost-efficient treatment for a significant proportion of patients with Parkinson’s disease. “The results from the past three years are showing us that the treatment is long-lasting and the effects continue for a time even after H the implant is turned off. ■

Laura Goncalves is a Communications Consultant at Lawson Health Research Institute.

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NEWS

Stem cells may heal lungs of premature babies

By Season Osborne ittle Olivia Eberts had oxygen tubes in her nose until after her first birthday. Because she was born prematurely, her tiny lungs were underdeveloped and she couldn’t breathe without oxygen. Ironically for Olivia, and many premature babies like her, the oxygen that saved her life also damaged her lungs, causing bronchopulmonary dysplasia (BPD), which is like starting out life with emphysema. This meant she needed to stay on oxygen even longer to help her breathe.

“She was on supplemental oxygen for so long, it was almost part of her identity,” says Jamie Eberts, Olivia’s mother.

Olivia was born on January 29, 2017, at 23-and-a-half weeks gestation, or 17 weeks too early. She weighed one pound, two ounces. Her twin brother Liam weighed only a few ounces more than she did. Both babies required oxygen and mechanical ventilation to keep them alive, and as a result, both developed BPD – the most common cause of death in premature babies. Sadly, baby Liam passed away a few weeks after he was born while Olivia remained in the Neonatal Intensive Care Unit (NICU) at The Ottawa Hospital for seven months.

In Canada, 1,000 babies suffer from BPD every year. Often babies with BPD, develop other chronic lung diseases, such as asthma, and many require prolonged oxygen and ventilation. They also have a high incidence of hospital readmissions in the first two years of life. Babies with BPD often have problems in other organs as well, such as the brain or the eyes.

When Olivia was finally discharged, she went home with an oxygen tank.

During the first year of her life, Olivia spent more time in hospital than out.

“Even now, a simple flu that put me in bed for a couple of days, put her in hospital and turned into pneumonia,” says Jamie. “It’s scary.”

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10 HOSPITAL NEWS AUGUST 2019

Olivia Eberts, who was born 17 weeks early, developed BPD – the most common cause of death in premature babies.

The doctor told Jamie that with Olivia’s respiratory issues, there would be no guarantee that Olivia will ever leave the hospital entirely.

“Currently there is no treatment for this disease,” says Dr. Bernard Thébaud, a neonatologist and senior scientist at The Ottawa Hospital.

He hopes to change the outcome for babies, like Olivia, who have BPD. “In the laboratory, we discovered that a particular type of stem cell can prevent BPD or regenerate newborn lungs,” says Dr. Thébaud, who is also appointed at CHEO and the University of Ottawa. “Our research uses stem cells, isolated from the umbilical cords of healthy newborns, to prevent the lung injury or even to some degree regenerate a damaged lung in the labora-

tory. We foresee that these stem cells, given during a certain time during the hospital stay of these babies, could prevent the progression of the lung disease.”

Dr. Thébaud and his research team are preparing for an early phase clinical trial to test the feasibility and safety of the stem cell treatment on premature babies.

“Stem cell research is incredibly innovative,” says Janet Brintnell, Clinical Manager of the NICU who has seen dozens of premature babies suffer from BPD. “Here, we have a very promising, emerging therapy that could prevent lung injury but also improve brain development and eye sight. It’s amazing when you think of what it may be able to do for the qual-

ity of life for the child, for their family and for our health-care system. It could reduce length of stay, hospital admissions, and reduce long-term outcomes. It could help these little ones lead healthier lives.”

“We are the only ones doing this kind of stem cell research in Canada, and there are only a few other teams in the world that are doing this,” says Dr. Thébaud.

Two years ago, when Olivia was in the NICU, Jamie and her husband Tim met Dr. Thébaud and wished his stem cell treatment could have been available to help heal their babies.

“What’s hard is we think, ‘But if we could’ve signed up for the trial? Would Liam be alive? Would Olivia be suffering?” says Jamie. “Even to this day, if www.hospitalnews.com

NEWS

MANY PREMATURE BABIES RELY ON SPECIAL MACHINES TO HELP THEM BREATHE. BUT FOR SOME, THE OXYGEN THAT SAVES THEIR LIFE CAN ALSO DAMAGE THEIR LUNGS. A STEM CELL TREATMENT SOON TO BE TESTED IN CLINICAL TRIALS AT THE OTTAWA HOSPITAL MAY HELP HEAL THE LUNGS OF PREMATURE BABIES.

we are asked to put Olivia in the trial as an older candidate, we will.”

Olivia is now a happy, active toddler who loves copying her older brother Jacob. Although, she still has BPD, it is increasingly manageable, and she no

longer requires supplemental oxygen.

Olivia may suffer respiratory illness her entire life, but one day, a stem cell treatment developed in Ottawa could mean that the next generation of baH bies with BPD won’t. ■

Dr. Bernard Thébaud and his team are preparing for an early phase clinical trial to test the feasibility and safety of the stem cell treatment on premature babies.

Season Osborne is the Publications Officer at The Ottawa Hospital.

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EVIDENCE MATTERS

Genome-wide sequencing for developmental delay: What’s next for families after a genetic diagnosis?

By Barbara Greenwood Dufour or many children who aren’t meeting expected developmental milestones, the cause isn’t easily found. Without other observable signs or symptoms or known external factors that could explain the developmental delay, these children undergo multiple diagnostic tests in an effort to get a diagnosis. Unfortunately, in many cases the tests don’t reveal a cause.

For families of children with unexplained developmental delays, it can be disheartening to have spent years on a “diagnostic odyssey” only to be told that no reason for their child’s condition can be found. If the condition has a genetic basis, however, genetic sequencing might be able to uncover the cause where traditional testing could not.

Although genetic sequencing was introduced into health care in the 1970s, recent developments in the biotechnology sector have made genome-wide sequencing faster and less expensive. These next-generation, or high-throughput, sequencing technologies require patients to undergo a standard blood draw that is sent off to a lab. Highly specialized professionals then sequence, analyze, and interpret the results to determine if there are genomic variations that could be responsible for the developmental delay.

Genome-wide sequencing isn’t broadly available in clinics in Canada and is, instead, conducted only as part of research studies primarily at academic centres. Yet, many Canadian parents of children experiencing developmental delays have become interested in this technology. If genome-wide sequencing were to be

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THE FACT THAT MANY FAMILIES ARE UNPREPARED TO DEAL WITH CERTAIN CONSEQUENCES OF A GENETIC DIAGNOSIS SUGGESTS THAT CLINICAL GENETICISTS AND GENETIC COUNSELLORS COULD PLAY A ROLE IN ALLEVIATING THEIR NEGATIVE FEELINGS. made broadly available, what might parents expect to experience? What supports might they need as they navigate a new odyssey after having found a genetic explanation for their child’s condition?

To find out, CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – conducted a review of the available qualitative studies that described the experiences of families that had accessed genome-wide sequencing to understand the reason for their child’s unexplained developmental delay. After screening the literature, CADTH reported on 13 studies, which captured the experiences using interviews, video-recorded consultations, and questionnaires.

According to the studies, most parents whose children received a diagnosis of a genetic disorder reported feeling relieved that their diagnostic odyssey was over. However, the need to know and understand the cause of their child’s condition is rarely the sole goal of families undergoing genetic testing. They also hope that the newly identified cause will open the door to new or different treatment options. But, for most parents, this isn’t the case.

Despite having received no more than a name and an explanation for their child’s condition – that is, the test results were not “clinically actionable” – some parents in the studies seemed able to adopt a positive outlook. They reported being hopeful that future research would soon provide a better understanding of their child’s condition, resulting in new treatments becoming available. Others indicated that they had been able to change their focus from treatment to helping their children reach their potential, gaining a sense of renewed purpose as a result.

But other families were left frustrated about the lack of clinical actionability. Many of them had expected that once the genetic disorder had been diagnosed there would be a treatment for it. They were unprepared to find out that, as is the case for many genetic disorders, there are no treatments available. Some parents also reported being unprepared to deal with other consequences – for example, the sense that the burden of care, previously shared with the health care professionals investigating their child’s condition, was permanently and solely on them; the concern that other family members, such as siblings of the child, might have the same genetic mutation(s); and a sense of

guilt about having passed the mutation(s) to their child.

The fact that many families are unprepared to deal with certain consequences of a genetic diagnosis suggests that clinical geneticists and genetic counsellors could play a role in alleviating their negative feelings. One of the studies – which observed consultations families had with a clinical geneticist and genetic counselor on issues such as disability care, reproductive decision-making, and emotional management – reported that parents found these consultations valuable.

CADTH’s review suggests that whether genome-wide sequencing leaves families with a positive or a negative outlook might be influenced by the quality and content of the conversations they have with clinicians beforehand. If access to this technology for the diagnosis of children with unexplained developmental disabilities were to be expanded to clinics in Canada, genetic counselling would likely help prepare families for the potential outcomes and implications, similar to the current practice of providing genetic counselling for all genetic testing.

The full qualitative review is freely available on our website. If you’re interested in this topic, you might also be interested in an upcoming Health Technology Assessment project that CADTH is conducting, in collaboration with Health Quality Ontario, on the use of genome-wide sequencing for patients with unexplained developmental disabilities and multiple congenital anomalies.

To learn more about CADTH, visit www.cadth.ca, follow us on Twitter @ CADTH_ACMTS, or speak to a LiaiH son Officer in your region. ■

Barbara Greenwood Dufour is a Knowledge Mobilization Officer at CADTH. 12 HOSPITAL NEWS AUGUST 2019

www.hospitalnews.com

NEWS

Charity eases access to medical care by providing free flights eople living in Canada’s biggest cities often take access to hospitals for granted.

But these sprawling healthcare hubs full of tests, treatments and all manner of medical specialists are not only used by people in the cities where they are located. Frequently, people who live in small or remote communities need to access the same hospitals, but must travel for hours by car or by bus, and sometimes struggle financially just to make the journey. Some will forego vital medical care altogether because distance or cost makes travel impossible.

Hope Air aims to remove these obstacles. It is the only Canadian charity that provides free flights to patients of all ages, and all medical needs who must travel far from home to access medical care.

One of the patients Hope Air helped is Rob from Timmins, Ontario, who flew with Hope Air when he was undergoing treatment for an advanced form of prostate cancer. As a father of five, and an active member of his community, all the time it took to travel for care took a toll on him. Receiving free flights for the treatments he had every two weeks eased his financial burden and allowed him to spend more time at home with his family. “Flying me back and forth meant a lot of what I worried about went by the wayside.� Rob says. “I could now focus on my health and recovery.� Currently in remission, Rob uses Hope Air less and less, but he wants to make sure that others can take advantage of their services. “Many don’t know this is available. I want to help spread the word about this great organization.�

Word of mouth from people like Rob and their family or friends is how 28% of patients find out about Hope Air. But health care workers are Hope

P

www.hospitalnews.com

Air’s key referrers, referring 46% of patients.�I work at a hospital and have helped patients connect with Hope Air to help make arrangements for themselves or a loved one,� says one referrer, “they feel such relief when they know they can attend a medical appointment safely, and that there will not be any financial burden.� Referrals from health care professionals are so valuable because the doctors, nurses and social workers who care for patients identify access issues early on and direct patients most in need to Hope Air before these obstacles cause cancelled appointments or undue stress.

Applications for patient flights can be made on hopeair.ca, by filling out the online travel request form or by calling 1-877-346-HOPE (4673). Applicants must have a confirmed medical appointment that is covered by their province’s health plan and must demonstrate financial need. Patients can fill out the application on their own or have a support worker or family member fill it out on their behalf.

Hope Air asks that applications be made two weeks in advance if possible, but quicker turnaround can be accommodated if necessary.

While Canadian airlines do generously donate flights to Hope Air, most flights are purchased with donor dollars. Corporate partners like Medtronic, CAA Club Group and WestJet Cares for Kids as well as gifts from foundations and individual donors, connect thousands of patients to medical care every year.

Accessing medical care should not be a burden. It’s thanks to health care workers advocating and submitting applications on behalf of their patients that Hope Air can reach as many people as they do. If you have a patient that could benefit from this service, H visit hopeair.ca. â–

Rob lives in Timmins and flew with Hope Air when he was undergoing treatment for an advanced form of prostate cancer.

Do you or someone you know need KHDOWKFDUH EXW FDQpW DĆŞRUG WR ĆŽ\ WKHUH" $SSO\ IRU D IUHH ĆŽLJKW DW hopeair.ca or 1-877-346-4673 Supported by

AUGUST 2019 HOSPITAL NEWS 13

FROM THE CEO’S DESK

Health care transformation – the view from the kids’ table

By Julia Hanigsberg What is the government doing?

It’s creating Ontario Health Teams, which include all the service providers and partners required for optimal health of the people within a particular geography. The mix includes primary care (physicians, nurse practitioners), home nursing and other home supports, hospitals, school health, children’s treatment centres, transportation, emergency responders and public health.

The other element of the transformation is something called Ontario Health. It brings together a single board of directors along with a number of health funding, coordinating, standards and quality-setting organizations (e.g. local health integration networks, Cancer Care Ontario, Health Quality Ontario and others).

How is the government doing this?

The short answer is: fast! The government indicated that it might approve three to five health teams in the first round, within only a few months, and then ended up receiving well in excess of 150 applications.

It’s important to remember that kids aren’t little adults. The way we care for children needs to be designed around

‘m not a fan of hyperbole.

So, take me at my word when I say that we are going through unprecedented health care transformation in Ontario. What is this transformation all about? What’s the view through the lens of child health? And what should you be paying attention to?

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IT’S IMPORTANT TO REMEMBER THAT KIDS AREN’T LITTLE ADULTS. If you are the parent of a child with a chronic condition or serious medical disorder, you likely have binders of records you cart around to hospitals because you don’t have confidence that anyone but you can keep track. Parts of the system don’t connect easily for families and seamless digital access to health records is uncommon. Often people wait too long for services or get “stuck” in hospitals because other parts of the system (e.g. longterm care) aren’t available when they need them.

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Julia Hanigsberg their wellness needs. Their health exists within the ecosystem of their family, school and community. Most children don’t receive their health care in specialty children’s hospitals.

Their care happens at the family doctor, at the local community hospital, in school, through public health. For 85 per cent of children who are mostly well, their health services experience will be routine and infrequent.

The investment in children’s health will reap a long-term return on population health. For example, treating chronic conditions early can prevent a greater need down the road. An even better example is prevention – keeping children from getting sick in the first place.

However, very ill children are moving into adulthood with ensuing health and social service needs. Making sure our “new” health system works for those children today, as youth, and into adulthood is something that must happen. But plans for children can be eclipsed because the chronic conditions of the aging population are taking up most of the air time. Seniors vote and kids don’t.

Across Ontario, family doctors are still often solo practitioners, leaving them and their patients vulnerable and frustrated. Highly integrated health systems include well-organized and integrated primary care. Pay attention to how and whether Ontario Health Teams are including and en gaging primary care providers.

We should care about the cost of the health system because, as taxpayers, we pay for it. We should care about how appropriately funded it is because we use it for ourselves and our family. We know that the government will want to drive cost out of the health system, but if our system gets cheaper before it gets better – organized, integrated and more streamlined – then we should be worried.

And finally, keep in mind that sign you see when you drive in your neighbourhood: “Slow down! Watch for children”. If the system we are creating doesn’t work well for the kids, it probably isn’t going to work for any of us in the long run.

Slow down. Watch for children.

The future of health care is depending H on us. ■

Julia Hanigsberg is president and CEO at Holland Bloorview Kids Rehabilitation Hospital. www.hospitalnews.com

NEWS

Smooth transition from hospital to home makes a difference for

NICU families

By Marie Sanderson

new approach to caring for sick and premature babies is supporting families as they transition from the hospital to home.

Building Opportunities for Optimal and Smooth Transition, or BOOST, is the only program of its kind in Canada. Babies in the program have a range of gestational ages; the one thing families have in common is they have had a prolonged stay in the NICU and could benefit from support as they transition to home.

For Afarin Salehi and Daphne Schibler, the approach to care is something both mothers continue to be grateful for.

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OUR BIGGEST GOAL IS TO BUILD CAPACITY, AND IF POSSIBLE RESILIENCY, IN PARENTS. “We had a bumpy start with our daughter Lily,” says Afarin. “Lily spent time in two NICUs. We were struggling with multiple illnesses and dealing with so many doctors. Having a small physician team caring for Lily was invaluable and really eased our worries.”

Daphne can relate to the stress of having a premature baby. Her daughter Violet was born at 24 weeks, weighing under one pound, and spent 133 days in Sunnybrook’s NICU. Daphne recalls the anxiety and long days spent in the NICU. She says the consistency in the care team boosted communication about her baby and improved her confidence in caring for Violet.

Babies in the program have a full spectrum of health needs. Families participating in BOOST see the same doctor for very long stretches. There are only three physicians involved in the program, which allows for frequent contact with not only each other, but also each family, in turn easing families’ stress.

“We’re really thinking, every step along the way, about not only what is happening with the baby in the unit, but what’s down the road as we approach discharge and the baby going home,” adds Dr. Paige Church, neonatologist and developmental paediatrician and one of the team of core physicians, which also includes Dr. Elizabeth Asztalos and Dr. Rudaina Banihani. “Our biggest goal is to build capacity, and if possible resiliency, in parents, and shift to them being the primary caretakers once their baby leaves the unit.”

The approach clearly worked for both mothers, who beam when talking about their daughters. Violet is currently 14 months corrected age (a premature baby’s chronological age minus the number of weeks or months she was born early). “She’s a busy girl from when she wakes up to when she goes to sleep. She’s walking and is very good at destroying our house on a daily basis,” laughs Daphne. “She just started gymnastics to get her energy out.”

Lily is now 18 months corrected birth, and is not only walking but running, loves dancing and speaking.

“Lily’s future once seemed so scary and unknown, but now it is much more hopeful as the same physicians who know Lily very well are following up on her development,” says Afarin.

“It’s very reassuring to know we are H not alone in this long journey.” ■

Photo credit: Kevin Van Paassen.

Daphne Schibler at home with her daughter Violet.

Marie Sanderson works in Communications and Stakeholder Relations at Sunnybrook Health Sciences Centre. www.hospitalnews.com

AUGUST 2019 HOSPITAL NEWS 15

ETHICS

Balancing denial, hope, and clinical recommendations

By Julie Hann and Andria Bianchi ocial workers are essential contributors to healthcare teams in both acute care and rehabilitative settings.

With the goal of social work being to address psychosocial issues through supportive and resource counselling, they contribute to successful patient-centred and, oftentimes, family-centred experiences. There are, however, many ethical dilemmas that social workers encounter because of the nature of their work. As a result of these dilemmas, social workers and bioethicists often work in collaborative partnerships to determine ethically defensible decisions in light of systemic constraints and pressures.

The following case serves as an example to help depict the kinds of ethical dilemmas that social workers may encounter in their practice. While aspects of this case will differ depending on the individuals involved, location of the patient and healthcare organization, etc., the general themes and resulting questions may still occur: Mr. J was recently admitted to an acute care hospital; this was his sixth admission in the last nine months. Mr. J has multiple medical comorbidities, such as diabetes, osteoarthritis, and chronic heart failure. Before his hospitalizations, Mr. J was living independently. Over time, however, his capacity to thrive while living independently has diminished. It has become difficult for him to leave the house to do groceries (his fridge is frequently empty), pick up medications, attend medical appointments, and socialize at the local seniors’ centre, all of which were activities that he used to do and value. It has also become challenging for him to clean his house and manage personal hygiene. He has limited financial resources and one son who resides in another country.

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SOCIAL WORKERS TRY TO HELP PATIENTS NAVIGATE THEIR OPTIONS WITHIN THE LIMITATIONS OF THE HEALTHCARE, COMMUNITY AND INDIVIDUAL ENVIRONMENTS. Upon attaining medical stability in acute care, Mr. J was transferred to a nearby rehabilitation centre for a short term admission. Mr. J informed the rehab team that the goal of his admission was to make enough functional gains to get back to his “old self” (i.e., to live independently, manage groceries, maintain upkeep on his household and personal care, walk to the seniors’ centre, etc.).

After receiving two weeks of intensive rehab, the clinical team agreed that Mr. J would not be able to make further progress in terms of physical gains. The team planned to arrange for Mr. J’s discharge, which would plausibly involve receiving therapy, medical care, and personal support at home (some of which would need to be privately funded).

Upon informing Mr. J of this news and the proposed plan, he responded by saying “I am going to get better” and that he just needs one more week of therapy to make gains. Mr. J expressed hopefulness about returning to his “old self” and begged the team to allow him to stay.

Social workers are frequently involved in discharge planning conversations that are similar to Mr. J’s; these situations often give rise to an influx of questions that are relevant to social work practice and have ethical implications. For example, if Mr. J cannot pay for additional care (since home care may require private finances), then is it ethically permissible to let him stay in rehab for a longer period of time? Should patients on our waitlist

be factored into the decision-making process about Mr. J (e.g., if a number of people are waiting for beds then should Mr. J’s discharge be forced)?

Since we cannot guarantee whether a person may make some functional gains, should we give Mr. J just one more week? Would we offer this to other patients? Ultimately, the question is: What is the most ethically defensible option to pursue for patients who maintain a persistent denial about making functional advances/attaining certain goals when the team has a clinically justified reason to disagree?

Should we ever accommodate patient requests in certain circumstances? If so, which ones?

The above questions are particularly complex in publically funded healthcare systems when all patients have a right to receive care and resources are limited. Additionally, our system has a duty to provide care that is in the best interest of patients, but clinicians and patients may disagree about what is best.

In order to answer these complex questions, it may be useful (at least as an initial step) to contemplate the purpose of a hospital and/or rehabilitation centre. If the purpose of a particular healthcare setting is to assist people to become medically stable (based on available evidence and clinical judgment) so that they can go home and strive to make further gains, then it may be defensible to discharge Mr. J.

This may be especially justifiable from an ethics perspective if Mr. J has resources available to help him thrive in the community (e.g. supportive family members, financial stability, secure housing), whereas we may owe more to patients who do not have such supports available (for more information on this, see April’s ethics column on equality vs. equity).

Sometimes what appears to be persistent denial serves a greater purpose in giving hope and motivation in otherwise discouraging circumstances.

Social work is framed by the following tenets: the presumption of patient/client capacity; the right to live at risk; the right to self-determination and choice; offering the most effective and least intrusive support; and maximum independence possible. These central tenets may seemingly conflict, however, when it comes to cases such as Mr. J’s. For instance, one may ask: How are a patient’s self-determination and choice, as well as maximum independence resolved in light of a clinical perspective which suggests that there are limited functional gains to be made?

There are no clear-cut solutions to address conflicting views about recovery between the rehab team and patients. Social workers try to help patients navigate their options within the limitations of the healthcare, community and individual environments. This means that sometimes a person will discharge home, despite believing they have not reached their full rehab potential. In other cases, they will continue in rehab, though often in a community program such as convalescent care or on a reactivation (reintegration) unit. In the latter case, the patient will have time to allow potential gains to occur and/or to adapt to a new “norH mal” before determining next steps. ■

Julie Hann, MSW, RSW is a Social Worker at the University Health Network and Andria Bianchi, PhD is a Bioethicist at the University Health Network.

16 HOSPITAL NEWS AUGUST 2019

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NEWS

New 7-day active rehab model speeds recovery

By Carla Wintersgill uffering from a lifetime of health problems caused by chemical exposure at a summer job in his youth, David Bergart recently found himself in acute care for four weeks following a stroke that caused him to lose feeling on the left side of his body.

Once stabilized, David was admitted to Runnymede’s Low Tolerance Long Duration Rehabilitation program (also known as slow stream rehab) with the goal of learning to walk again. Fortunately, the hospital had recently undergone an organizational change to help David get back to his life sooner.

Runnymede was proud to introduce a 7-day model of care in February 2019 for its active rehab, slow stream rehab and medically complex programs to maximize the number of therapy minutes patients received per week.

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Runnymede Healthcare Centre patient David Bergart practices walking with physiotherapy assistant Keri Pitelli.

“Runnymede Healthcare Centre put patients’ needs at the centre of all decision-making. We adopt current best practices to help patients achieve their treatment goals and move on to their next care destination or return home,” said Raj Sewda, VP, Clinical

Operations & Quality, Chief Nursing Executive & Chief Privacy Officer.

The slow stream rehab program provides patients with a slower, less intense form of therapy. It is designed for patients who are unable to tolerate a more active form of rehabilitation due to their level of disability after injury or surgery.

Runnymede’s clinical team works in partnership with patients to restore their mobility and develop the skills and understanding they need to adapt to their new reality and return home. Admission in the program was a boon to David, who had originally been slated for discharge from acute care without additional rehabilitation.

“Without Runnymede I would be sitting at home doing nothing,” David said.

By moving to a 7-day model, slow stream rehab patients receive an increase in therapy minutes per week from 150 to 325 minutes, representing a 116.6% increase. Since the introduc-

tion of the 7-day model in February, there has already been a noted reduction in average length of stay for slow stream rehab patients.

“The fact that Runnymede has rehab every single day including weekends is a major part of why I’m walking again,” David said.

David was discharged from Runnymede at the end of June after spending just over a month in the slow stream rehab program. He left walking with the assistance of a wheel walker.

“I met my goal,” David said.

“By introducing the 7-day model, Runnymede is moving more patients faster through our programs, opening up beds in this crucial rehab program and helping to ease the bottleneck in acute care hospitals,” Raj said. “By embracing our rehab philosophy and working together, we are helping more patients get back to their lives, quicker H than ever.” ■

Carla Wintersgill is a communications specialist at Runnymede Healthcare Centre.

Study identifies new potential target in glioblastoma

By Ana Gajic NA-binding protein inhibitor ID1 helps maintain cancer stem cells in brain, breast and skin cancer, making tumours resistant to chemotherapy, research suggests.

Researchers are hopeful that new strategies could emerge for slowing the growth and reoccurrence of the most common primary brain cancer in adults, glioblastoma, based on the results of a study published today in Cancer Research.

Research led by Toronto’s St. Michael’s Hospital and The Hospital for Sick Children (SickKids) suggests the protein ID1 is critical to tumour initiation and growth and also impacts the disease’s response to chemotherapy.

ID1 is a protein that keeps other genes from being activated or repressed by binding to their activators or inhibitors. In this work, scientists found that

D

ID1 helps maintain cancer stem cells in glioblastoma, making them less susceptible to treatment.

“The field has postulated for years that cancer stem cells are a small population within the tumour but critical because they mediate treatment resistance and cancer resistance,” said Dr. Sunit Das, a scientist at St. Michael’s Keenan Research Centre for Biomedical Science and associate scientist at The Arthur and Sonia Labatt Brain Tumour Research Centre at SickKids.

“We’ve now found proof of that speculation.”

Researchers found that when they “turned off” the protein ID1 in lab models and human cells using CRISPR technology or a drug that is traditionally used to treat psychosis and Tourette’s syndrome – pimozide – glioblastoma tumours slowed down. The team also found that turning off the

protein altogether helped tumours become less resistant to chemotherapy.

Glioblastoma is an aggressive form of brain cancer, representing 15 per cent of all primary brain tumours, and is often difficult to treat. Therapy generally involves the combination of several approaches to control the disease, but there is currently no cure. The diagnoses of the late Tragically Hip singer Gord Downie and U.S. Sen. John McCain have raised the profile of glioblastoma in recent years.

“The average survival rate for glioblastoma is less than two years and we unfortunately don’t have too many options to offer these patients,” said Dr. Das, who is also a neurosurgeon at St. Michael’s.

“Our findings suggest that we may be able to enhance the effectiveness of therapies we already have, such as chemotherapy, as opposed to taking

many years to create entirely new therapies.”

In lab models, researchers found that inhibiting ID1 slows the progression of tumours in glioblastoma, breast adenocarcinoma and melanoma. In human tissue, they found that the protein caused cells to be more resistant to chemotherapy treatment in glioblastoma. Turning off this protein using the medication pimozide increased overall survival and caused glioblastoma tumours to recur less frequently, progress less and grow more slowly.

“Targeting the protein with medication may present a novel and potentially promising strategy for patients with glioblastoma,” Dr. Das says.

The next steps for this research, Dr. Das explained, are to look at the development of new inhibiting medications for ID1 and commence a trial to H ensure that the targeting is effective. ■

Ana Gajic works in communications at Unity Health Toronto. www.hospitalnews.com

AUGUST 2019 HOSPITAL NEWS 17

NURSING PULSE

Faith, fear and flight Eight Canadian nurses evacuate Haiti but not their mission to help an impoverished community oo scared to sleep and jolted to her feet by each unfamiliar sound near the wall of the Hope Grows Haiti mission, RN Marie Nieminen prayed that the medical expedition where she had found her life’s purpose was not going to become the place where she would die.

Nieminen was the team leader among eight Canadian nurses stranded at the remote mission in February 2019, when the Haitian capital of Port-au-Prince exploded in waves of political violence that killed several, forced the Canadian Embassy to close, and made perilous the 90-minute drive from the compound to the airport.

None of the nurses knew exactly what was going on. They had no access to television, internet, news reports, or this dire advisory from the American state department: “There are currently widespread, violent and unpredictable demonstrations in Port-au-Prince and elsewhere in Haiti…” the advisory read. “Local police may lack the resources to respond effectively to serious criminal incidents, and emergency response, including ambulance service, is limited or non-existent.”

The 53-year-old Nieminen did know this: she had left for the week-long trip to Haiti Feb. 6 with a 10-day supply of medication that if reduced too quickly, or stopped suddenly, would create medical risks. When she learned violent blockades would prevent her team from getting to the airport for their return flight on Feb. 13, she cut her daily dosage in half. By Feb. 18, she began suffering from withdrawal symptoms.

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CHILDREN NOT ONLY LACKED BASIC SHELTER, FOOD AND MEDICAL CARE, THEY OFTEN WENT WITHOUT THE COMFORT OF BEING HELD BY PARENTS WHO HAD SO MANY KIDS AND FACED SO MANY BURDENS. That evening, she heard first-hand a warning given to mission owners Gord and Heather Rodin. A trusted Haitian friend and volunteer told them word had spread that their mission had medical supplies, money, gasoline and other things of value.

They needed to evacuate the next day because their compound, guarded by security personnel with no weapons, could soon become a target.

“I was more frightened than I ever have been,” says Nieminen, whose 27-year-old daughter Kirsten was among the eight volunteer nurses. “I didn’t sleep that night. Every noise, every time I saw a flashlight, I got up to take a peek (outside).”

Nieminen’s fear, for the moment, competed with the sense of purpose she had felt when in 2016 she helped to create the mission’s medical clinic on the first of six or seven trips to Haiti’s Petit Paradis, a village already poor before an earthquake and tsunami in 2010 killed seven community members and knocked down homes.

Nieminen’s Haitian mission is her life’s work. Each time she returns, she sees children, parents and elderly community members who have transitioned from malnutrition to better health, from helplessness to hope.

Her efforts captured the attention of RN Tracey Hotta, who travelled to the Haiti mission in 2017. Hotta was stunned by what she saw. Some families were sleeping on floors in plywood homes with neither plumbing nor running water. Children not only lacked basic shelter, food and medical care, they often went without the comfort of being held by parents who had so many kids and faced so many burdens.

Her first trip was so spiritually rewarding, Hotta returned in February, this time with RN Charline Ramgotra. While Hotta and Nieminen were pleased to see improvements in the children and the elderly they had met previously, Ramgotra was stunned by the depths of poverty.

Her surprise was matched by her admiration of the mission and the work it was doing. In addition to the medical clinic, Hope Grows Haiti mission has created a school with English and music classes and a feeding program for children and elderly, helps to build homes, provides clothing and offers bible study.

A day after the nurses arrived in Haiti, protests began Feb. 7 in the capital. Political violence isn’t new to Haiti, where protesters accuse the government of engaging in corrup-

tion while doing nothing to combat poverty. On Feb. 8, Canada issued a travel advisory, warning Canadians to avoid all travel to Haiti: “Access to the (airport) may be difficult and could be blocked…Criminal activity is especially prevalent (in) downtown Port-au-Prince, where armed gangs operate.”

Five violent days later, Canada closed its embassy.

With Canadian officials offering no help, the group of eight volunteer nurses did what came naturally – they took action. They continued to help Haitians while arranging for a GoFundMe page to pay for a private helicopter to the airport. They raised more than $19,000, double what they sought, so the nurses earmarked the extra to the mission and booked a helicopter for the morning of Feb. 18.

The helicopter pilot struggled to find them, at first because he had been given incorrect coordinates, and later, because his helicopter was too far off the coast to easily see the small compound. Each time he flew near, the nurses waved brightly coloured sheets and clothes, and even laid out a Canadian flag.

“When the helicopter touched ground, a lot of us started crying,” Nieminen says.

Back on home soil, Nieminen, Hotta and Ramgotra say their ordeal has left them even more determined to return to help a mission that has provide incredible help to people who need it.

Says Ramgotra: “We all said we’d H be back.” ■

Jonathan Sher is senior writer for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario.

This article was originally published in the March/April 2019 issue of Registered Nurse Journal.

18 HOSPITAL NEWS AUGUST 2019

www.hospitalnews.com

Jim walks the walk.

Jim Vigmond’s handshake is as firm as his commitment to helping his personal injury clients receive fair verdicts. This founding partner is also committed to his philanthropic pursuits. Among his many charitable organizations, Jim raises funds and travels to Cambodia every year to assist underprivileged women house themselves while giving them the opportunity to go to law school.

Lending a hand comes naturally. With exceptional experience in spinal cord and brain injury law, Jim knows that his legal contributions will make a profound difference in the outcome of his client’s life. For Jim, their right to fair compensation isn’t just of vital importance; it’s his professional mission.

Jim doesn’t have to be in court to talk the talk. Jim would be quick to tell you that despite all his success, nothing compares to the joy of actually being able to make a difference in someone’s life.

To learn more about Jim visit www.oatleyvigmond.com/jim Proud Member

1.888.662.2481 oatleyvigmond.com

PAEDIATRICS

Safer medicines for children long overdue

By Dr. Robert Connelly afe and appropriate medications are an integral tool to manage the health of many Canadians. Canada’s federal government is once again considering the merits and affordability of a national pharmacare strategy. Canada is currently the only country in the world with universal health care that excludes drug coverage. While there are anticipated financial savings (the result of bulk purchasing) to consider, a national pharmacare strategy must be purposely designed to address appropriateness and accessibility of medications for the entire population, including Canada’s children and youth.

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Many children rely on medications for routine illnesses, and in some cases to treat rare, serious or multiple conditions. Many of these medications have not been proven safe or effective for use in children. Children are not tiny adults – their developing bodies process medications in different ways than adults. Significant developmental changes, especially during the first year of life, affect how children’s bodies deal with medications and how medications, in turn, affect their bodies. Nevertheless, in Canada today, best estimates suggest 75 per cent or more of the medications prescribed to children have never been specifically

CANADA IS CURRENTLY THE ONLY COUNTRY IN THE WORLD WITH UNIVERSAL HEALTH CARE THAT EXCLUDES DRUG COVERAGE. tested or approved for use in children and youth. Further, many medications administered for children and youth are not specifically manufactured for the smaller dosage required. In order to administer these to children, the adult form of the medications need to be altered – split, crushed, dissolved.

This “compounding” of medication has resulted in serious variability in ef-

fectiveness when used in children. Notably, commercially available pediatric formulations of many medications are manufactured and available in other countries. We can and must do better.

Policy frameworks that direct the development, approval and reimbursement of medicines in Canada were designed with adults in mind, neglecting the unique characteristics of children

Children’s Healthcare Canada accelerates excellence and innovation in health systems caring for children and youth.

Representing health delivery organizations serving children, we collaborate with members and partners to inform and advocate for integrated, high quality child, youth and family centred healthcare, wherever it is delivered.

We create peer networks and knowledge mobilization channels that enable children’s health providers to share and learn with each other and from innovators within and beyond health care.

Learn more about becoming a member: 20 HOSPITAL NEWS AUGUST 2019

info@childhealthcan.ca

@ChildHealthCan

childhealthcan.ca www.hospitalnews.com

PAEDIATRICS

Children’s Healthcare Canada sets sights on

innovative, more integrated systems serving kids

By Emily Gruenwoldt egardless of your interest or experience in children’s health care – whether a parent of a medically complex child, a front line provider striving to deliver best in class care, or an administrator faced with relentless cost pressures – chances are you identify with the need for change in health systems serving children and youth.

In Canada today, there are just short of eight million children and youth between the ages of 0 and 19, representing 22 per cent of the total population. This number is projected to grow by 1.2 million over the next 15 years. The health of these children, as evaluated based on a series of international indicators, points to several well documented areas of concern. Internationally speaking, UNICEF data tells us that Canada ranks 25th among the world’s 41 richest countries in overall child and youth well-being, a middle of the pack position that has persisted unchanged for more than a decade.

Surprising to some, Canada lags farthest behind in measures related to child

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Emily Gruenwoldt health. This is concerning not only in the context of the health of today’s children, but also with respect to prosperity of Canada more broadly. It is concerning because research demonstrates clear linkages between unhealthy children and unhealthy adults, that poor health and low income go hand in hand, and that the consequences of both poverty and poor health make large demands on our health system (and beyond).

Lastly, and most significantly, it is concerning because we have every opportunity to prioritize investments in children’s health, developing systems

and services that put children on the path to life-long health. A win for children. A win for families. A win for a prosperous Canada.

This is the vision behind the transformation underway at Children’s Healthcare Canada. As a national association representing health delivery organizations who serve children and youth (formerly known as CAPHC – the Canadian Association of Pediatric Health Centres), our unique mandate is leverage purposeful partnerships to accelerate excellence and innovation in health systems caring for children.

As the number of children living in Canada grows, so too will their demand for health services across the continuum of care. In order to improve our international ranking, but more importantly to create a population of healthy vibrant children and youth, we need more agile and integrated systems of care that are inspired by a “big picture mindset”, with leaders who cultivate a culture of shared leadership that begins with patients and their families.

While our members focus on delivering world class care for children and youth, as a national organization, our

sights are set on four key priorities: (1) informing the development of innovative and integrated health systems within and across jurisdictions, (2) sharing evidence and accelerating the implementation of high quality child, youth and family centred care, wherever it is delivered, (3) uniting strategic partners to foster excellence in children’s health, and (4) informing and influencing public policy that improves children’s health and health systems.

Children are not tiny adults. Systems and structures that are purpose built for adults, are not (often) appropriate for children. Children have unique diseases and disorders. Their bodies react differently to medications than adults.

They rely on a wider range of service providers and family members or care givers play a significant role in treatment. Children’s Healthcare Canada, hand in hand with our members and the families they serve, will work tirelessly to advocate for investments in children’s health, and ensure the health systems evolve in such a way that best H serves this unique population. ■ Emily Gruenwoldt is CEO, Children’s Healthcare Canada

at least one prescription medication.

Let’s make sure these medications are H purpose-built for kids. ■ Robert Connelly, MD, MBA, FRCPC is

President, Pediatric Chairs of Canada Associate Professor and Head, Department of Pediatrics, Queen’s University

Safer medicines and youth. While change is coming, in Canada today, manufacturers are neither required to generate nor provide data on drug safety and efficacy in children, and Health Canada can request, but not compel, a manufacturer to submit results of any such studies. As a result, the Expert Panel on Therapeutic Products for Infants Children and Youth commissioned by the Canadian Council of the Academies in 2014 observed that most drugs given to children are used off-label, without regulatory review of information about safety and efficacy and without appropriate dosages, forms, or formulations. While in some cases, studies to demonstrate safety and efficacy for children’s use have not been done, in other instances, such studies have been done for other jurisdictions (commonly the US or European Union) but study results are not submitted during drug approvwww.hospitalnews.com

al in Canada. Thus, information may exist but may not be put into service for Canadian children’s health.

Access to safe and effective medications should be a priority for Canada.

Recognizing this, several pan-Canadian child health stakeholder organizations are united in their call for a permanent and appropriately funded Expert Pediatric Advisory Board, accountable to the Minister and Deputy Minister of Health. This board would advise on all regulatory, reimbursement and research related to drugs for children and youth. Further, we believe Health Canada must proactively solicit and review pediatric specific drug data, when it is reasonably expected that a particular drug could be used to treat children or youth.

The case for pediatric medications is compelling. Each year, about half of Canada’s seven million children use

AUGUST 2019 HOSPITAL NEWS 21

PAEDIATRICS

Medical social workers play vital role in supporting SickKids families

By Jane Kitchen and Maia Leggott he Social Work program at The Hospital for Sick Children (SickKids) in Toronto offers support to families at their most vulnerable – when their child has a complex or serious medical issue.

SickKids has a team of 60 medical social workers, all MSWs, who empower families in their ability to manage the impact of diagnosis and support them throughout the child’s care journey.

“Our medical social workers are a huge part of the highly specialized medical teams at SickKids,” says Dr. Jonathan Golden, Director of Collaborative Professional Practice (Psychology and Social Work). “They bring their specialized training to both medical and mental health care plans offered at SickKids.”

Social workers take a holistic approach to their work with families, who experience many stressful transitions when caring for their sick child, such as changing health status, starting or returning to school and transitioning into adult services. They are at the front line to provide mental health services to patients, siblings, and parents as they journey through their experience of acute and chronic illness.

“We can’t emphasize enough how important mental health support is for these families,” says Christina Bartha, Executive Director, Brain and Mental Health Program. “We recognize that our families and patients are facing very challenging circumstances that can be short-term, long-term or both.

Our social workers provide essential therapeutic support and education and are particularly sensitive to the diversity of need across the many populations that we serve.”

The social work team is connected to various programs across the hospital, such as adolescent medicine and psychiatry, working with physicians, nurses, and allied health team members

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Adina, 4, with Kathy Netten, Social Worker in Paediatrics at SickKids.

SOCIAL WORKERS TAKE A HOLISTIC APPROACH TO THEIR WORK WITH FAMILIES, WHO EXPERIENCE MANY STRESSFUL TRANSITIONS WHEN CARING FOR THEIR SICK CHILD. in an interdisciplinary care approach.

They work with both inpatient and ambulatory populations, including acute care (such as in the NICU or emergency department), and chronic care (for kids with ongoing medical issues).

“The biggest transition a family experiences is into the experience of illness,” says David Brownstone, Professional Practice Lead, Social Work. “It is unexpected and it is like arriving in a new country where you don’t know the way.

Social workers help develop the map for them to best navigate this journey.”

This was the case for Gitty Samsonowitz, who first met a social worker at SickKids when her daughter Adina was in the NICU. She had never had an experience with a social worker, yet quickly realized how valuable her support was in helping her make sense of their new reality.

Adina, now 4, is a medically complex patient and has been admitted to hospital 48 times in four years, with many stays being over a week in length. Once Adina was transferred to Paediatric Medicine at SickKids,

her family met Kathy Netten, a social worker in the Complex Care Program.

Whether in clinic, on the wards, or in the community, Netten connects with family members to provide psychotherapy that addresses the losses and trauma they face.

Netten says it is an incredibly stressful time for families when they are at the hospital; not only do they have everything they are dealing with in their lives generally but now they have the additional layers of an ill child and the concerns that this brings with it, such as juggling childcare, work, and finances. Social workers can help families logistically with these concerns and also to manage the accompanying stress.

Additionally, watching your child suffer takes a toll. ”Seeing your child in pain is really hard, especially when as a parent you try to comfort your child,” says Netten. “They see them going through these very difficult experiences day after day and when they feel their child is suffering that creates great emotional stress.”

The uncertainty is also hard. “With a child such as Adina with special needs, they’re so sick, but then they’re stable, and you have to worry about the developmental piece, and I grieve that loss all over again when she’s stable,” says Samsonowitz. “I had a really hard time accepting that she would have a limited life, we don’t know where she’s headed. Accepting that was very difficult for me.”

Her social worker has helped her immeasurably, Samsonowitz says: “Kathy helped me see Adina who she is aside from the diagnosis. She doesn’t just help me through the hard times, she’s always there celebrating as well.

She has saved us so many times.”

Positive feedback on the team is standard: “I am delighted that family feedback consistently speaks to the vital role our social workers play in their children’s care at SickKids,” H says Bartha. ■

Jane Kitchen is a Communications Specialist and Maia Leggott is a Communications and Public Affairs Intern at SickKids.

22 HOSPITAL NEWS AUGUST 2019

www.hospitalnews.com

Sometimes,it’s the tiniest among us who need the most nurturing to

grow.

Prolact RTF, Prolact HM®, PremieLact ®, and Prolact CR® are currently not available in Canada.

Optimize growth, minimize complications.

Premature infants begin life with decreased nutrient stores, altered gastrointestinal absorption, increased caloric expenditure, and a critical need for rapid growth.1 Early and appropriate advancement of fortification is achievable with an exclusive human milk diet (EHMD) and has been associated with weight gain exceeding targeted standards, and length and head circumference growth meeting targeted standards.2 When used as part of an EHMD, Prolacta’s neonatal nutritional products are clinically proven to improve health outcomes3,4,5 for critically ill, extremely premature infants weighing between 500 and 1250 g* (1 lb 1 oz to 2 lbs 12 oz) at birth, in the neonatal intensive care unit, as compared to cow milk-based fortifier or cow milk-based preterm formula. So choose Prolacta. Help them grow. There’s a great big wonderful life waiting for them.

Learn more at prolacta.com/grow. * Outcome measures were statistically based on mean weight data.

1. Georgieff, MK. Nutrition. In: MacDonald MG, Mullett MD, Seshia MMK, eds. Avery’s Neonatology: Pathophysiology & Management of the Newborn. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. 2. Hair AB, Hawthorne KM, Chetta KE, et al. Human milk feeding supports adequate growth in infants ) 1250 grams birth weight. BMC Res Notes.

2013;6:459. 3. Sullivan S, Schanler RJ, Kim JH, et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatr. 2010;156(4):562-567. doi:10.1016/j.jpeds.2009.10.040. 4. Cristofalo EA, Schanler RJ, Blanco CL, et al. Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. J Pediatr. 2013;163(6). doi:10.1016/j.jpeds.2013.07.011.

5. Abrams SA, Schanler RJ, Lee ML, Rechtman DJ. Greater mortality and morbidity in extremely preterm infants fed a diet containing cow milk protein products. Breastfeed Med. 2014;9(6):281-285. doi:10.1089/bfm.2014.0024.

©2018 Prolacta Bioscience, Inc. All rights reserved.

CAPHC 10/18

PAEDIATRICS

Feeling stuck with a challenging mental health or substance use case?

BC Children’s Hospital COMPASS Program can help

By Dr. Jennifer Russel and Jonah Starr n September 2018, the Child and Youth Mental Health Program at BC Children’s Hospital launched COMPASS, a new service to support physicians, as well as mental health and substance use clinicians across the province in being better equipped to support the complex needs of children and youth up to age 25 struggling with mental health and substance use challenges.

Throughout the country, access to mental health services is limited. Epidemiological data in British Columbia suggests that 180 000 youth (0-25) require mental health services each year in our province. Of those, 130 000 seek support from their family physician and 25 000 received specialized services through the community child and youth mental health teams. However, approximately 50 000 youth do not receive any mental health services at all.

In response to these alarming statistics the COMPASS Program was born.

Learning from successful programs in the United States such as the Massachusetts Child Psychiatry Access Program (MCPAP) and the Seattle Partnership Access Line (PALS), Compass Program was designed to support clinicians to provide evidence based mental health and substance use treatment for children and youth close to home.

It is widely recognized that family physicians and community mental health and substance use clinicians are over stretched in their capacity to meet the needs of this vulnerable and ever growing population. The COMPASS Program provides a unique service that reduces the barriers to accessing psychiatry and mental health/ substance use support by providing telephone consultation directly to the provider when they need it the most.

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The COMPASS team is comprised of local and remote Child and Adolescent Psychiatrists as well as a diverse team of mental health and substance use clinicians who all specialize in delivering evidenced based psychological treatments and pharmacologic recommendations required for optimal mental health and substance use care.

In addition to telephone consultation and support, the COMPASS team is able to provide direct psychiatric assessments via video conferencing, tailored education and training, and coordinate referrals to local mental health resources in the child’s home community to further bolster care.

From there, following the initial call to COMPASS, the provider is offered ongoing follow up with the COMPASS team to ensure he/she/they is feeling supported moving forward to care for their patient. The provider is then given a confidential letter that outlines all of the COMPASS interventions to date and recommendations moving forward to keep on the client’s file.

Although it remains early days, the COMPASS Program has been able to reduce visits to hospital emergency departments, shorten existing hospital stays, and strengthen the capacity and confidence of primary healthcare providers to manage this complex population. In less than one year ( Sept/18-June/19), COMPASS has enrolled 750 providers and managed over 800 unique cases and represents a new approach in supporting the provision of comprehensive mental health and substance use care in communities throughout BC.

was looking for clinical practice help with a tough case and a practitioner called me back within a week. The conversation was very helpful. This is an especially good support that goes beyond the medical model of diagnosis but offers some fine tuning of the treatment options. particularly good for a rural practitioner.

2. Very easy access and strong support, follow up and timely access to specialist and expert guidance and consultation. This is a great resource especially for low resource communities. Please inform all providers of this valuable service.

3. I am very grateful for the Compass line at BC Children’s. As a family physician striving to meet the ever-increasing mental health needs of the children and youth in my practice, the Compass line has improved the quality of life of my patients and greatly increased my professional satisfaction. My interactions with the various psychologists, psychiatrists, and other allied health professionals have been nothing short of enriching and informative. For example, I feel so much more comfortable now initiating and monitoring medical treatment. In addition to being better equipped with clinical knowledge and

skills, I feel both empowered AND encouraged to care for my own patients. In fact, because of Compass, I have a new-found interest in children and adolescent psychiatry.

4. Overall, my interaction with Compass has been one of the most positive interactions I have had with child psychiatry in my 10 years of practice. I felt heard, and that the clinicians I was speaking with “got it”, recognizing that patients can easily fall through the cracks, especially for those who live outside of Vancouver but who come into Vancouver for care. I commend the Compass team for putting this resource together and will definitely H be spreading the word about it. ■

TESTIMONIALS 1. I have had three calls with Compass now and they have all been helpful.

On a recent call I specified that I

Dr. Jennifer Russel M.D. F.R.C.P.C is the Clinical Director of Compass Line at BC Childrens Hospital and Jonah Starr M.S.W. R.S.W. RCC is a Clinical Social Work/Therapist in Vancouver BC. 24 HOSPITAL NEWS AUGUST 2019

ww w ww.h h ita alnew ws.ccom m www.hospitalnews.com

PAEDIATRICS

First-in-Canada digital system will improve care for critically ill children

By Julie Dowdie t’s something no parent even wants to imagine, let alone have happen – their child is in hospital and begins to get worse.

Unfortunately, it’s a situation that does routinely occur in hospitals. And in many cases, the nurse or another member of the care team contacts the doctor and they hurriedly return to the bedside. However, a new digital system introduced at Markham Stouffville Hospital (MSH) will help to prevent these types of critical situations.

Known as the Bedside Paediatric Early Warning System, or BedsidePEWS, the technology “helps healthcare professionals identify children whose illness may become more serious in a short period of time and react in a faster and more coordinated way,” says Elena Pacheco, Vice President, Support Services and Transformation at MSH.

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MSH Chief of Paediatrics, Dr. Deepa Grewal (right) reviews the electronic BedsidePEWS system with Registered Nurse Maxine Palmer. clinic, but they can still track other patients’ vital sign trends in real time and work with the team to make any necessary changes to their care plan.”

“BedsidePEWS truly combines the art of caring with the science of best practice to improve health

outcomes and patient experience for all our children and their H families.” ■

“WITH ELECTRONIC BEDSIDEPEWS, PHYSICIANS, NURSES AND OTHER MEMBERS OF A PATIENT’S CARE TEAM CAN REMOTELY MONITOR THEIR STATUS AND ACCESS THEIR ELECTRONIC MEDICAL RECORD ANYWHERE IN THE HOSPITAL,” BedsidePEWS is currently a paper-based tool. MSH is the first hospital in Canada to implement an electronic version to further enhance the care and outcomes of young patients. p “With “Wit electronic BedsidePEWS, physicians, nurses and other memphysic bers ber of a patient’s care team can remotely monitor their status and acm cess their electronic medical record anywhere in the hospital,” says Dr. Deepa Grewal, Chief of Paediatrics at MSH. “For instance, a physician may be caring for a patient in another area of the hospital, su such as in the Emergency Departmentt or o an outpatient

Developed by the Toronto-based start-up Bedside Clinical Systems in partnership with SickKids, BedsidePEWS is one of 11 projects that have received funding from the second round of Ontario’s Health Technologies Fund.

The fund is being administered by the Ontario Centres of Excellence.

The electronic BedsidePEWS system was launched on MSH’s paediatric inpatient unit this past July and there are plans to expand the system within the hospital.

“We’ve recently introduced the paper-based BedsidePEWS in our Emergency Department and are examining its effectiveness in improving the care experience for our paediatric patients there,” Pacheco notes.

Julie Dowdie is a Senior Communications Specialist at Markham Stouffville Hospital. www.hospitalnews.com

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PAEDIATRICS

Working together

to save kids’ lives, kilometres apart

By Ellie Stutsman hen three-year-old Lucas Waring woke up feeling sick earlier this year, his mom Nikki thought it was the flu. However, it quickly progressed to a swollen tummy and erratic breathing. Nikki knew something was very wrong and took him to the closest hospital, Niagara Health’s Welland Site.

His x-rays showed that his abdomen was filling with air and pressing on other organs. It was getting bigger by the second and his health was rapidly deteriorating. Soon, the pressure would cut off his blood supply and stop his heart.

The Niagara Health emergency team knew he would need to be transferred to Hamilton Health Sciences’ McMaster Children’s Hospital (MCH) to determine the cause of air build up, but first they had to save his life. They connected to MCH’s pediatric emergency team using the newly launched tele-resuscitation system to get immediate help.

The tele-resuscitation system – the first of its kind in Ontario – uses video conferencing-like technology from industry partners, Ontario Telemedicine Network. High-definition cameras are set up in the resuscitation room at each Niagara Health hospital. When the emergency team at MCH logs into the system they get a bird’s-eye view of the patient and room. The MCH team can control the view, as well as speak and listen to the team at Niagara Health. This allows the MCH team to remotely coach the Niagara Health team through advanced techniques to stabilize patients as quickly as possible.

“We’re focused on reaching beyond our walls to provide the best care possible to our most critically ill patients.

This includes drownings, car accidents, poisonings, and acute asthma attacks,” says Dr. Chris Sulowski, deputy chief of pediatric emergency medicine at MCH and tele-resuscitation lead. “With this system, we can give advice as if we’re standing there ourselves.”

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Lucas Waring benefitted from the new teleresucitation system at McMaster Children’s Hospital.

Unbeknownst to Nikki, Lucas was the first live case using the tele-resuscitation system.

“Everything was happening so quickly,” says Nikki. “I didn’t think anything of it when I saw the doctors were talking to a different set of doctors on a TV screen. Everyone was calm and knew what to do so I didn’t even realize how life-threatening his condition was.”

Once the system was up and running the MCH team instructed the Niagara Health team to stick a needle in Lucas’ abdomen to let the air out. They saw an instant improvement in Lucas as air

gushed out the needle and the pressure in his belly decreased. Colour came back to his skin. They began to prep him for transport. Though they had relived the pressure, air was still filling Lucas’ abdomen so the needle had to stay in place until he was at MCH. “It’s rare for an emergency doctor at a non-children’s hospital to see a child in Lucas’ condition,” says Dr. Madan Roy, deputy chief of pediatrics at MCH and chief of pediatrics at Niagara Health. “The ability for the Niagara Health and MCH teams to work together as if they were in the same room saved his life.”

At smaller community hospitals, complex children’s emergency cases are far less common, but the closest emergency department is the best place to go for immediate medical attention.

“The physical distance between McMaster Children’s Hospital and our hospitals can be a challenge in life-threatening situations,” says Dr. Rafi Setrak, chief of emergency medicine at Niagara Health. “The tele-resuscitation system eliminates that challenge. It allows our teams to work collaboratively and more efficiently when time is of the essence.”

Since these situations are not overly common, the teams anticipate using it once or twice a month at most. But it has already proven its value.

When Lucas arrived at MCH, the team knew his situation well and he was in surgery within the hour. It turned out his intestines had twisted, cutting off blood supply and causing a portion of his stomach to rupture. The air that regularly travels through the stomach was flowing out the hole into his abdomen. The team at MCH untwisted his intestines and removed the damaged portion of his stomach.

“A couple days after Lucas’ surgery Dr. Roy came to check on him,” says Nikki. “That’s when I learned it was the first time they’d used the live video system. I was not only surprised, since it seemed like they’d used it many times before, but extremely grateful because they were able to save Lucas’ life.”

Lucas’ scare hasn’t left him with any long-term consequences. His stomach is slightly smaller, but it hasn’t changed his eating habits and he’s back to being an outgoing, healthy three year old.

The team behind the tele-resuscitation project at MCH is looking to extend the system’s reach to other community hospitals within the region it serves so even more children can benefit from this technology, and the specialized expertise of its pediatric H emergency team. ■

Ellie Stutsman is a public relations specialist at Hamilton Health Sciences.

26 HOSPITAL NEWS AUGUST 2019

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PAEDIATRICS

Making hospitals a pain-free zone

By Vanessa Gomez ospitals can be a scary place for children. Fear of unknown spaces, unfamiliar faces and pain from needles or procedures are challenges faced by children and their parents.

A new initiative at Stollery Children’s Hospital – Solutions for Kids in Pain (SKIP) – is working to end these fears by putting evidence-based solutions into practice to help minimize children’s pain and give healthcare professionals and families easy access to pain-management information and tools.

The Stollery is now one of four hubs in Canada for SKIP, thanks to a $1.6 million federal grant and funding support from the Stollery Children’s Hospital Foundation, through the Women and Children’s Health Research Institute (WCHRI).

“Two-thirds of children in hospital experience painful procedures with no pain management, which can be traumatizing for not only the child, but for their families as well” says Dr. Samina Ali, a pediatric emergency physician and Western Canada’s SKIP Hub Lead at the Stollery.

“We’ve been able to identify specific pain-management strategies to help with these painful experiences, but translating those findings into practice within the hospital can be a challenge.

With the help of SKIP, we’re able to speed up this process.”

Kathy Reid, a Clinical Nurse Specialist for Policy and Practice at the Stollery, has been working to improve the assessment and management of pain in children for more than 20 years.

“Procedure-related pain can increase anxiety for children and parents,” says Reid. “We are certainly hearing a lot about trauma from parents who have had to hold their children down during very painful procedures.”

It’s an anxiety that one mother, Brandie Thomas, knows all too well. Her son, Mason, was born with only half of his heart functioning, and required multiple procedures at just three-days-old.

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With therapy dogs, music therapy and play and self-expression activities, children are able to better understand their illnesses or procedures.

During a particularly stressful emergency, Thomas remembers feeling scared as she watched her seven-month-old baby endure painful prodding.

“It’s hard as a parent to watch that,” says Thomas. “You feel suffocated.

You know it needs to get done, but it’s hard to see your child like that. It was years ago, but I still remember exactly how I felt.”

Due to this anxiety, some patients refuse procedures, may be less likely to diligently follow-up with after-care, or miss important vaccinations.

A recent culture shift has allowed certain practices to help young ones cope with procedure-related pain – things such as breastfeeding, skin-toskin contact, numbing creams and, for older children, teaching them distraction and relaxation techniques – which are beginning to be integrated into wider practice.

The Stollery’s Child Life Program also provides children with the ability to cope with their circumstances.

With therapy dogs, music therapy and play and self-expression activities,

children are able to better understand their illnesses or procedures.

Working with families, healthcare providers, researchers, and policy-makers, SKIP will empower patients and their families through research and knowledge – giving them active voices in their care and the confidence they need to address any concerns with their medical team.

By improving children’s experiences with pain, healthcare professionals will continue to provide high-quality care H that meets the needs of every patient. ■

Vanessa Gomez works in communications at Alberta Health Services. www.hospitalnews.com

AUGUST 2019 HOSPITAL NEWS 27

PAEDIATRICS

Increasing system capacity for autism diagnosis

through ECHO Ontario Autism

By Salina Eldon pproximately one in 66 Canadian children are diagnosed with autism spectrum disorder (ASD).

The increase in prevalence of ASD has meant that clinicians have had to adjust their thinking around what was once considered a rare disorder. ASD remains a complex neurodevelopmental disorder whose etiology is not yet fully understood. Without an objective biomarker to aid in diagnosis, the identification and diagnosis of ASD is primarily based on information from family report and systematic interactive observations of the child.

The legacy of ASD diagnostic assessment is one of limited access to speciality evaluations in tertiary centres that tend to be located in more urban areas.

However, this model no longer meets the system’s needs based on the high prevalence of ASD. Building capacity for community-based diagnostic and care models is now essential to providing timely care to children with ASD and their families. Last year, Holland Bloorview Kids Rehabilitation Hospital began to implement the Extension for Community Healthcare Outcomes (ECHO)™ model to address the need for a wider reach in knowledge sharing and to play a role in advancing the diagnosis and treatment of ASD.

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WHAT™IS THE ECHO MODEL? Developed in New Mexico by Dr. Sanjeev Aurora, the ECHO approach is an “all teach, all learn” model. It combines medical education and care management in a way that de-monopolizes specialty knowledge, providing clinicians in rural and underserved areas the skills and capability to care for patients with complex conditions.

Using inexpensive video-conferencing technology, ECHO links expert specialist teams at an academic ‘hub’ with primary care clinicians in local communities. The interactive video-conference sessions – accessible by smart phone, tablet, laptop, or a computer with a webcam – combine didactics containing information on relevant topics, along with mentoring and de-identified patient case discussions.

WHAT IS ECHO ONTARIO AUTISM? “Through ECHO Ontario Autism, Holland Bloorview provides community practitioners with the knowledge and support they require to diagnose and manage the symptoms of ASD in their own practice,” says Dr. Melanie Penner, developmental paediatrician and clinician investigator – Autism Research Centre, Holland Bloorview.

“This enables families to receive care in their own community instead of having to travel long distances for tertiary care.”

In addition to Dr. Penner, the ECHO Ontario Autism hub team at Holland Bloorview includes Dr. Evdokia Anagnostou, child neurologist and senior clinician scientist; and Dr. Jessica Brian, psychologist and clinician-investigator – both celebrated names in their field. Other members include an occupational therapist, registered nurse, behaviour therapist, and family advisors who are parents of children with ASD. Including the family perspective is what makes this model in Ontario unique, and is a testament to Holland Bloorview’s ongoing commitment to involve families in all aspects of program, service and care development. The parent advisors provide insight on areas in-

(L-R) Salina Eldon, Dr. Evdokia Anagnostou, Dr. Melanie Penner, Dr. Jessica Brian. cluding system navigation and how doctors can better communicate with families. “…I want to reiterate that in 38 years of doing CME in practice settings, ECHO has been far and away the best – and most carbon neutral – that I have had the pleasure of doing…it truly augmented the value and pleasure of working in a community practice setting,” says Dr. Anthony Ford-Jones, paediatrician.

The program, which is fully funded by the Ministry of Health and LongTerm Care, has offered 18 video conference sessions since October 2018, with a total of 50 participants across 26 geographic locations. The majority of participants are paediatricians, however additional primary care providers, such as family doctors and nurse practitioners, are also involved. ECHO

Ontario Autism is a self-approved group learning activity as defined by the Maintenance of Certification (MOC) Program of the Royal College of Physician and Surgeons of Canada (Section 1), and MOC credits can be earned.

For the remainder of this summer, ECHO Ontario Autism is holding a pop-up series open to physicians, nurse practitioners and allied health professionals. Each session includes a didactic of the day’s topic, which were based on suggestions from participants, followed by discussion and questions. This September will see the start of cycle 2 sessions, continuing until May, and targeted at health professionals who diagnose ASD. For more information on how to sign up, visit hollandbloorview.ca and search H for ‘ECHO Autism’. ■

Salina Eldon is the project manager of ECHO Ontario Autism at Holland Bloorview Kids Rehabilitation Hospital.

28 HOSPITAL NEWS AUGUST 2019

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PAEDIATRICS

New technique developed to detect autism in children esearchers have developed a new technique to help doctors more quickly and accurately detect autism spectrum disorder (ASD) in children.

In a study led by the University of Waterloo, researchers characterized how children with ASD scan a person’s face differently than a neuro-typical child. Based on the findings, the researchers were able to develop a technique that considers how a child with ASD gaze transitions from one part of a person’s face to another.

According to the developers, the use of this technology makes the diagnostic process less stressful for the children and if combined with existing manual methods could help doctors better avoid a false positive autism diagnosis.

“Many people have autism, and we need early diagnosis especially in children,” says Mehrshad Sadria, a master’s student in Waterloo’s Department of Applied Mathematics. “The current approaches to determining if someone has autism are not really

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child-friendly. Our method allows for the diagnosis to be made more easily and with less possibility of mistakes.

The new technique can be used in all ASD diagnosis, but we believe it’s particularly effective for children.”

In developing the new technique, the researchers evaluated 17 children with ASD and 23 neuro-typical children. The mean chronological ages of the ASD and neuro-typical groups were 5.5 and 4.8, respectively.

Each participant was shown 44 photographs of faces on a 19-inch screen, integrated into an eye-tracking system.

The infrared device interpreted and identified the locations on the stimuli at which each child was looking via emission and reflection of wave from the iris.

The images were separated into seven key areas of interest (AOIs) in which participants focussed their gaze: under the right eye, right eye, under the left eye, left eye, nose, mouth and other parts of the screen. The researchers wanted to know more than how much time the participants spent

looking at each AOI, but also how they moved their eyes and scan the faces. To get that information, the researchers used four different concepts from network analysis to evaluate the varying degree of importance the children placed on the seven AOIs when exploring the facial features.

The first concept determined the number of other AOIs that the participant directly moves their eyes to and from a particular AOI. The second concept looked at how often a particular AOI is involved when the participant moves their eyes between two other AOIs as quickly as possible. The third concept is related to how quickly one can move their eyes from a particular AOI to other AOIs. The fourth concept measured the importance of an AOI, in the context of eye movement and face scanning, by the number of important AOIs that it shares direct transitions with.

Currently, the two most favoured ways of assessing ASD involve a questionnaire or an evaluation from a psychologist.

“It is much easier for children to just look at something, like the animated face of a dog, than to fill out a questionnaire or be evaluated by a psychologist,” says Anita Layton, who supervises Sadria and is a professor of Applied Mathematics, Pharmacy and Biology at Waterloo.

“Also, the challenge many psychologists face is that sometimes behaviours deteriorate over time, so the child might not display signs of autism, but then a few years later, something starts showing up.

“Our technique is not just about behaviour or whether a child is focussing on the mouth or eyes. It’s about how a child looks at everything.”

The study, Network Centrality Analysis of Eye-gaze Data in Autism Spectrum Disorder, authored by Waterloo’s Faculty of Mathematics researchers Sadria, Layton and Shahid Beheshti University’s Department of Physics graduate student, Soroush Karimi, was recently published in the journal Computers in Biology and H Medicine. ■

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AUGUST 2019 HOSPITAL NEWS 29

LONG-TERM CARE NEWS

Including social workers in interdisciplinary meetings

By Karen Lok Yi Wong ike many other healthcare settings, in long-term care (LTC), we often have meetings with clients, families and interdisciplinary professionals. There are many different types and names of these meetings, such as care conferences and ethics rounds. As a social worker working in LTC, I have been involved to facilitate these meetings. In different facilities, this role can be held by professionals from different disciplines. So what are the advantages in having the social worker to take on this role?

One advantage is that although the social worker may not have deep knowledge on each specific professional discipline, he or she often has a broad spectrum of knowledge of different disciplines such as nursing, dietary, physiotherapy, occupational therapy, recreation therapy and more.

This gives social worker a more holistic view when reviewing a case and be more objective when working with professionals from different disciplines.

Another advantage is a social worker’s specialized skills in communication. Communication is at the heart of the social work profession. Many communication skills can be applied to meeting facilitation. For examples: • Summarizing skills after long discussions to give the participants of the meetings a time and space to refresh and reflect; • Checking skills to reduce communication breakdowns in discussions among different parties; • Interpretation skills translating technical terms used by professionals of different disciplines into terms which clients and families can understand; • Conflict resolution skills such as negotiation and mediation when there are conflicts among clients, families and/or professionals; and • Boundary setting skills – In cer-

L

tain circumstances, social worker may need to remind participants the guidelines and boundaries of the meeting (e.g. being respectful and listen to each other, not to interrupt and be mindful with inappropriate language and behavior).

Another advantage is that a social worker will provide valuable information, analysis and insights from their expertise in these meetings. Examples of their expertise include: • Social backgrounds of a client such as birthplace, immigration, education, employment and religions, and the implications of these backgrounds on client’s healthcare, personal care and finances; • Complex family dynamics such as relationships between client and spouse/partner, between client and adult children, among adult children, what are the implications of these relationships to client’s healthcare, personal care and / or finances, and what are the advantages and

disadvantages for family members to meet together and separately; and • Law such as the laws and important documents and resources regarding client’s healthcare, personal care and finances decision making when his or her decision making capacity on these areas are questionable, or he or she is not able to make decisions on one or all of these areas.

One more advantage is that while the atmosphere of meetings in a LTC setting could become tense because of the nature of issues discussed (e.g. limited resources in this setting, ethics), a social worker can help to de-escalate the tension with their professional training in relational work.

This can include small but significant things such as offering tea and coffee and making sure that the meeting room is comfortable for participants.

This can also include more specialized things such as counselling and professional emotional support; for example, offering brief emotional sup-

port during the meeting when a family member gets emotional discussing about the goals of care of their loved one who is dying.

A social worker can invite client, family and/or professionals to the meeting and do preparation work with them separately prior to the meeting with their professional training on planning so that each party is intellectually and emotionally better prepared for the meeting and utilize the meeting time and opportunity better. For examples, social worker can give the professionals a summary of the development of the issues going to be discussed in the meeting and heads ups to things to pay attention to which may happen in the meeting (e.g. a family may have inappropriate language to the professionals and how the team can keep the space safe), or provide the client and family guidelines how they can better express their concerns to the interdisciplinary team (e.g. preH paring notes, listing out key points). ■

Karen Lok Yi Wong BA, MA, BSW, RSW, RTC, CT was trained in social policy at University of York, the United Kingdom and social work at UBC, Canada. She is a registered social worker in British Columbia.

30 HOSPITAL NEWS AUGUST 2019

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LONG-TERM CARE NEWS

Plant versus animal

protein in long-term care

By Dale Mayerson and Karen Thompson ealth Canada recently published Part 1 of the new Canada’s Food Guide. One of the recommendations is that Canadians “choose protein foods that come from plants more often”. Dietitians across Ontario are considering this statement when planning menus for long term care (LTC) homes.

H

PROTEIN 101 Protein is made up of 20 amino acids, nine of which are essential and must be provided by the diet. After the body breaks down the proteins that we eat, we use these amino acids to create new cells – this includes skin, muscle, bone, blood, tendons, ligaments, organs and enzymes that are all made out of protein. In total,

about 16 per cent of the body is protein. This is quite high when considering that up to 70 per cent of the body is water. Since our bodies are constantly breaking down and rebuilding body structures, we need a small but ongoing supply of protein foods to keep us healthy. Animal sources of protein provide complete protein that has all of the required amino acids. Plant sources of protein provide incomplete protein, since each source does not contain all of the required amino acids. When plant sources of proteins are eaten together, it is possible to obtain all essential amino acids needed, e.g. legumes and grains. Adequate protein is especially important for seniors, where breakdown is happening faster than rebuilding.

LTC MENU PLANNING RECOMMENDATIONS FOR PROTEIN There have been a number of changes to the recommendations around protein over the years. In the 1993 standards, the Ontario Ministry of Health specified that daily protein items on the menu needed to provide “2 servings weighing 50 to 100 grams cooked weight of meat containing 7 grams of protein for each 30 gram serving, or the equivalent grams of protein in alternatives”. The emphasis at this time reflected the eating patterns of the majority and was slanted towards providing animal protein as the “centre of the plate” items, i.e. meat, poultry, fish and eggs were the main options. A usual serving size of plant

protein such as vegetarian chilli typically would only meet this standard when served in an excessively large portion. For many standard or regular menus, beans and lentils were often served only in salads or soups or were included in stews along with meat.

The current regulations governing LTC and part 1 of the new CFG recommendations allow for consideration of a broader range of protein sources.

The LTC regulations 79/10 are less specific, indicating that LTC menus provide for “adequate nutrients, fibre and energy for the residents based on the current Dietary Reference Intakes (DRIs)” and that they provide for a variety of foods, including fresh seasonal foods, each day from all food groups in keeping with Canada’s Food Guide.

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LONG-TERM CARE NEWS Comparison: ½ cup cooked ground beef

½ cup cooked black beans

19 g protein

8.1 g protein

0 g fibre

8 g fibre

2.1 mg iron

1.9 mg iron

14 mg calcium

25 mg calcium

15 mg magnesium

64 mg magnesium

66 mg cholesterol Source: Canadian Nutrient File There is less focus on providing a specific amount of protein at each meal and more on providing an adequate amount throughout the day.

Both animal and plant proteins should be encouraged on the menu based on resident wishes. According to the Dietary Reference Intakes for males 70+ years old, the Recommended Daily Allowance for protein is 46 grams per day, and this should be from a variety of sources. This number is actually quite low for older residents because there is often a greater need for protein related to skin integrity. Another standard frequently used for this population is to provide 1 gram of protein per kg of body weight– if someone weighs

0 mg cholesterol 70kg, the goal would be to provide 70g protein daily. Canada’s Food Guide specifies the following foods as recommended protein foods: legumes, nuts, seeds, tofu, fortified soy beverage, fish, shellfish, eggs, poultry, lean red meat including wild game, lower fat milk, lower fat yogurts, lower fat kefir, and cheeses lower in fat and sodium.

ACCEPTANCE OF PLANT PROTEINS While it is good to have expanded menu options, this can only be done with resident support and approval.

Those who are used to meat and potatoes as an expected dinner may not be satisfied with plant protein items. Will

black beans, tofu and chick peas be as popular on the menu as beef, chicken or fish? Many homes, particularly those in areas where there is considerable ethnic diversity in their populations are already offering this type of menu choice while other homes may be experimenting with this for the first time.

Animal based meals will still be on the menu, but menu planners may be looking forward to testing new plantbased ideas for the population they are serving. The unknown is whether this generation of seniors now in LTC will be willing and interested in trying food items that were previously unknown to them? This is a broad generalization, since Canada has been growing beans and lentils for decades and many who grew up during the depression may have been raised on these less expensive, high protein plant foods.

Menu planners will need to test recipes with residents, possibly focusing on the home’s Residents Council members, or the home food committee if one exists. Testing recipes can be a fun and challenging experience, and both residents and staff should have input into the development of new recipes and menu ideas.

NUTRITIONAL DIFFERENCES BETWEEN ANIMAL AND PLANT PROTEIN CHOICES Protein: With the exception of gelatine, animal foods provide all 9 essential amino acids. This is desirable because it gives the body all the necessary raw material needed to create body structures. In contrast, a plant food may be missing a single amino acid. Each group of plant food is missing a different amino acid, so combining them is the best way to ensure that all amino acids are available, even in the absence of animal foods. Some examples of combinations that provide all essential amino acids are bean burrito (black beans and corn) or hummus (chick peas and sesame seeds).

Fibre: Fibre is found in all plant foods and lacking in all animal foods.

Fibre is an important nutrient for everyone, but especially for seniors.

Many residents in LTC have constipation, which could be due to lack of physical activity, poor fluid intake, side effect of medications, and more.

Continued on page 34

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AUGUST 2019 HOSPITAL NEWS 33

LONG-TERM CARE NEWS Continued from page 33

Plant versus animal protein Providing more fibre-rich foods on the menu is helpful to alleviate this situation. Soluble fibre also helps to lower blood cholesterol.

Vitamins and Minerals: Both plant and animal foods provide vitamins and minerals, however there are some differences. For example, vitamin C is found in plants while vitamin B12 is found in animal foods. Certain minerals may be more easily absorbed from animal foods, since plants have a binding agent that may limit mineral absorption. Everyone benefits from a wide variety of both plant and animal foods throughout the day to ensure that all nutrient needs are met.

Antioxidants and phytochemicals: These nutrients, which are primarily from plants, protect the body from cancer, heart disease, vision loss and many other illnesses. Antioxidants reduce the damage to cells caused by oxidation. Phytochemicals provide the body with nutrients to protect cell and organ structures.

Examples of phytochemicals include lycopene and lutein.

CONCLUSION Menu planners await the Health Canada release of Part 2 of Canada’s Food Guide. Once further guidance or direction has been provided, these considerations will become part of the menu planning process.

It is likely that it will make it easier to provide options that provide more plant protein entrees and to better serve a growing vegetarian clientele. Residents can look forH ward to new recipes and flavours. ■

Dale Mayerson, BSc, RD, CDE, and Karen Thompson, BA Sc, RD are Registered Dietitians with extensive experience in Longterm care. They are co-authors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians in Canada.

34 HOSPITAL NEWS AUGUST 2019

Dementia and noise:

How one long-term care home is enhancing its sound environment to support residents’ mental health

By Rebecca Ihilchik eet Sarah Condran, music therapist at Arborstone Enhanced Care (Shannex) in Halifax, Nova Scotia. As a point-of-care clinician working with sound every day, she sees firsthand that noise can affect the mental health of older adults, especially those living with dementia.

Building on an initial sound audit pilot at Arborstone in 2017, Sarah is spearheading a CABHI-supported project to enhance sound environments in long-term care at her facility and beyond. She joined us for a Q&A about her project.

M

HOW DOES NOISE IMPACT THOSE LIVING IN LONG-TERM CARE SETTINGS? In long-term care, sources of noise can include everyday things such as laundry carts, staff conversations, elevators, dishes, and the like. When our bodies are subject to loud or abrupt sounds, our body enters into a state of stress. Stress has many adverse effects on the body and can affect our bodies’ ability to heal and generally be well.

For those who already have cognitive impairments, once their attention is interrupted, it is difficult to get back.

This can prevent nursing staff from completing seemingly simple procedures, create agitation, and reduce residents’ ability to effectively engage in leisure activities and therapeutic sessions. When environmental triggers such as noise are regulated, there is an incredible value to cognitive clarity.

WHAT DOES YOUR CABHISUPPORTED PROJECT AIM TO ACHIEVE? Through our CABHI project, we hope to enhance the sound environments in long-term care communities and create realistic guidelines and suggestions that other facilities will

Sarah Condran is a music therapist at Arborstone Enhanced Care (Shannex) in Halifax, Nova Scotia. be able to follow. We will build on an initial sound audit pilot project to assess noise levels in our facility, as well as make physical changes to the living spaces and provide additional training to increase awareness of mental health and the impact that environmental stressors can have.

WHAT ARE SOME EXAMPLES OF PRACTICAL CHANGES THAT COULD BE MADE AS A RESULT OF THE PROJECT? • Changes to physical environment, such as creating quiet spaces for therapy, recreation, family visits and quiet leisure to occur, as well as repairing and replacing regularly used equipment as necessary.

• Offer and enhance our mental health education for staff that is specific to seniors • Changes in practice as needed – for example, how can we enhance our

residents’ ability to communicate with staff and each other during meal times?

• Enhance leisure spaces and resources, by renovating recreation spaces so they are welcoming, or providing engaging leisure resources interesting for residents as well as families, volunteers, and staff.

WHAT’S YOUR EXPERIENCE BEEN AS A POINT-OF-CARE WORKER INVOLVED WITH A PROJECT LIKE THIS? Because the team knows I am working on this project, they are coming to me with examples of how noise has affected either a resident or themselves.

I am seeing that noise also can cause stress for staff. Being a part of the clinical team and having the experience on the floor means I am able to bring a different but important point of view H to a project like this. ■

Rebecca Ihilchik is the Marketing & Communications Specialist at the Centre for Aging + Brain Health Innovation (CABHI). www.hospitalnews.com

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SAFE MEDICATION

The importance of a holistic approach to medication incident reporting and analysis

By Grant Fuller and Certina Ho s a part of the efforts to improve patient safety and promote continuous quality improvement, many organizations have mandated participation in medication safety programs.

A key component of these programs is the reporting and analysis of medication incidents. It is therefore important that healthcare practitioners understand the different methods available to analyze medication incidents and the value of a comprehensive approach to incident analysis.

Two broad approaches exist for examining medication incidents: quantitative and qualitative analyses. Quantitative analysis provides an overview of medication incident data using descriptive statistics (e.g. frequency distribution tables of common medications involved in incidents).

Qualitative analysis consists of a more in-depth review of the narrative data from medication incident descriptions.

When analyzing groups of medication incidents, both quantitative and qualitative approaches offer valuable information and shared learning opportunities. However, they are also subject to limitations (Table 1).

A thorough incident analysis requires: 1) a detailed description and understanding of the incident(s); (2) identification of the underlying contributing factors; and (3) documentation and dissemination of recommendations for system-based improvements. Using either approach in isolation of the other may lead to steps that are essential to a comprehensive incident analysis being omitted.

Statistical trends may be missed by examining incident narratives alone and recurring themes from incident descriptions may go unnoticed by focusing only on the quantitative data.

A combination of both approaches, quantitative and qualitative, is necessary to gain the full picture of med-

A

Quantitative Analysis

Qualitative Analysis

Benefits

• Offer a quick summary of incident rates • Allow monitoring of trends

• Allow identification of casespecific contributing factors

Limitations

• Does not address case-specific contributing factors

• Does not identify incident rates • Can be time-consuming

Table 1. Benefits and Limitations of Common Incident Analysis Approaches ication incidents and ultimately learn from them.

CASE EXAMPLE AND DISCUSSION As part of an examination of medication incidents reported to ISMP Canada, a quantitative analysis was initially conducted on 267 incidents that were associated with patient harm in a province. Of the 267 incidents, four were classified by the reporters as associated with severe patient harm.

The incident narratives were then examined qualitatively; one of the severe harm incident descriptions is paraphrased below: “A patient took Ciprofloxacin 500 mg for 7 days as per the physician’s prescription. On the last day of therapy, the patient felt symptoms of tendinitis in both legs. The pain worsened each day for a week. The patient sought care from a walk-in clinic.”

While this event was classified by the reporter as associated with severe patient harm, it is clear upon analyzing the narrative of the incident that the patient experienced an adverse drug reaction (ADR) rather than a medication incident. An ADR is a non-preventable side effect of a medication (i.e. an undesirable effect that may occur under normal use conditions of a medication), with tendinitis/tendon rupture being a rare but known side effect of the fluoroquinolone drug class (e.g. Ciprofloxacin). This contrasts with the definition of med-

ication incidents, which are preventable cases of inappropriate medication use. This distinction is important as the inclusion of ADRs in medication incident data offers very limited value to incident analysis of which the goal is to reduce preventable patient harm by generating improvements to the medication-use system. While ADRs should be reported to programs where they can be shared with healthcare practitioners and the pharmaceutical industry (i.e. MedEffect Canada https://www.canada.ca/en/ health-canada/services/drugs-healthproducts/medeffect-canada.html), their inclusion in a medication incident reporting and learning system can be misleading.

The above case example was categorized as one of the four or 25% of the severe harm reports in a group of 267 incidents that were associated with patient harm in a province. Solely looking at the quantitative analysis of this data set may distract the province’s attention from truly preventable medication incidents or areas of improvements in the medication-use system. Our qualitative analysis of the narratives of the same data set also revealed other discrepancies that were not caught by the quantitative approach. These included duplicate incident reports, incomplete reports, and reports that were misclassified as being associated with patient harm – from our interpretation of the incident description provided by the reporters,

these would be better classified as “no harm” incidents or “near misses”.

Most healthcare professionals intend to report medication incidents as accurately and completely as possible for the purpose of shared learning.

However, practitioners who report medication incidents are human: they may be fatigued, unfamiliar with the reporting systems, or very distraught after discovering an incident, etc. A holistic view to medication incident reporting and analysis is necessary to ensure that any recommendations being considered should be able to address the underlying contributing factors that may have led to the incidents.

CONCLUSION It is the expectation of those who were involved in medication incidents and those who took the effort to report them that incident analysis findings and recommendations be shared in order to prevent similar events from occurring. To fulfill this expectation would require a commitment of time, resources, and expertise needed for comprehensive incident analyses.

Summarizing the quantitative data with descriptive statistics, charts, and graphs is not enough. A deeper look at the narratives surrounding the incidents is also needed. Adopting a holistic approach to incident reporting and analysis offers a valuable opportunity for healthcare professionals to improve our medication-use system and preH vent future patient harm. ■

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

36 HOSPITAL NEWS AUGUST 2019

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NEWS

What causes

type 2 diabetes?

By Gabrielle Bauer hat causes type 2 diabetes: genes, diet, activity level? All three? Dr. Gillian Booth, an endocrinologist and scientist in the Centre for Urban Health Solutions at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto, has been exploring another cause: where you live. Her research, which has been funded by Diabetes Canada (formerly Canadian Diabetes Association), has linked “walkability” – how well a neighbourhood supports walking, cycling, and keeping the car in the garage – to lower rates of obesity and type 2 diabetes.

“Type 2 diabetes is a complex problem with roots in genetics, the environment and individual behavioural choices,” says Dr. Jan Hux, President and CEO of Diabetes Canada. “A second, less appreciated contributor to the growing diabetes epidemic is the role of the environment, specifically factors such as the walkability of neighbourhoods, food security and local access to health-related facilities and services.”

W

WHY DOES WHERE YOU LIVE MATTER? In a Toronto Diabetes Atlas entitled, “Neighbourhood Environments and Resources for Healthy Living– A Focus on Diabetes in Toronto,” Booth and her team put together statistics of 140 neighbourhoods in Toronto.

In some suburbs, they found rates of diabetes two to three times higher than the norm. Income and ethnic background, while undoubtedly play-

ing a role, “didn’t fully account for the differences in diabetes rates across neighbourhoods,” she says. “Although diabetes can be prevented through physical activity, healthy eating and weight loss, we suspected that the environment in which one lives is also an important indicator of one’s risk.” Further research in this area by Dr. Booth and her team determined that this was indeed the case.

In 2016, she and her colleagues published a related study called “Association of Neighborhood Walkability with Change in Overweight, Obesity, and Diabetes” in the Journal of the American Medical Association (JAMA), which was selected by the American Heart Association’s Lifestyle and Cardiometabolic Health Council as “one of the most impactful papers of 2016.” The study looked at these various factors over a 12-year period in 15 municipalities in Southern Ontario, further building on and supporting the findings that they have previously reported.

While overall rates of obesity have been increasing, Booth says they have remained stable in the most walkable areas – such as the Beach neighbourhood of Toronto. Furthermore, these highly walkable communities had a decline in the number of new cases of diabetes in the population each year.

She herself lives in a walkable urban neighbourhood, and either walks or takes public transit to work. “Driving doesn’t actually get you places faster when you’re downtown,” she adds.

Dr. Gillian Booth

“ALTHOUGH DIABETES CAN BE PREVENTED THROUGH PHYSICAL ACTIVITY, HEALTHY EATING AND WEIGHT LOSS, WE DETERMINED THE ENVIRONMENT IN WHICH ONE LIVES IS ALSO AN IMPORTANT INDICATOR OF ONE’S RISK.” – DR. BOOTH WHAT CAN BE DONE TO HELP CANADIANS LIVE HEALTHIER LIVES? “For people who are at risk of developing diabetes, behavioural choices that promote obesity increase that risk,” says Hux. ”Improving the diet and physical activity level of persons at high risk has been shown to reduce the risk by nearly 60 per cent.”

Urban planners who are involved in designing cities have been looking at Booth’s findings. For example, in the Region of Peel in Ontario – an area with especially high rates of di-

abetes – “is now taking a population health perspective when reviewing development submissions,” she says.

Booth has been part of meetings between provincial health, planning, and transportation officials to create policy changes that promote walkability. “It’s not a revolution,” she says modestly, “but there’s a lot of movement in the area.” A well-chosen word indeed.

Learn more about the new Canadian Diabetes Prevention Program launched by Diabetes Canada and LMC. ■ H

Gabrielle Bauer is a freelance writer. www.hospitalnews.com

AUGUST 2019 HOSPITAL NEWS 37

NEWS

A continued commitment to health equity with First Nations

By Brad Buie collaborative partnership between area First Nations and Interior Health, one of British Columbia’s regional health authorities, is setting the course to better health services and improved health outcomes for First Nations in B.C.’s Interior region.

On June 5, 2019, the seven First Nations of the interior region of B.C. and Interior Health (IH) re-signed their Partnership Accord. First signed in 2012, the Accord represents continued collaboration and commitment to improving health equity for Aboriginal people. This includes theNlaka’pamux, Dãkelh Dené, Secwepemc, Tsilhqot’in, St’at’imc, Ktunaxa, and Syilx Nations The Métis Nation of B.C., while not a signatory to the Accord, also work in partnership with Interior Health towards this goal.

“This is an important milestone on a long journey to culturally safe and equitable healthcare for our people,” says Charlene Belleau, Secwepemc Nation Representative and Partnership Accord Leadership Table Co-chair. “Our growing partnership with Interior Health is a key part of this process.”

“I am personally committed to this work, and to cultural safety and cultural humility being embedded in all aspects of care across Interior Health,” says Susan Brown, Interior Health’s President & CEO. The work is a priority for Brown, and for all of Interior Health (IH).

Ten years ago, IH implemented the Aboriginal Patient Navigator (APN) program as a way to improve the health care experience. APNs support Aboriginal patients and families in IH’s 22 hospitals and throughout several communities, helping make connections to health-care services and providing cultural support. The APNs also collaborate with other health-care workers in early identification and assessment of patient needs, and partic-

A

Syilx Nation artist Clint George unveils a metal sculpture of an abalone shell smoke bowl, a sage grass bundle and an eagle feather at Penticton Hospital.

AN IMPORTANT COMPONENT IS THE REQUIREMENT FOR STAFF AND PHYSICIANS TO COMPLETE LEARNING MODULES RELATED TO RECONCILIATION, AND THE HISTORY AND EXPERIENCE OF FIRST NATIONS IN BRITISH COLUMBIA. ipate in discharge planning to support patient care and independence.

The APN program is part of a larger, long-term commitment to improving health outcomes for Aboriginal peoples. Another important component is the requirement for staff and physicians to complete learning modules related to reconciliation, and the history and experience of First Nations in British Columbia. A key learning in the training is that safety is defined by the people receiving the service, not those providing it.

Gaining a new understanding of cultural safety can also be achieved through experiences. This year, IH emergency department nurses from a

more urban setting participated in an exchange program with First Nations Community Health nurses in rural communities.

“Wanda, a Community Health Nurse, enlightened me on the cultural history of the community and her experiences providing care through the veil of fear which still exists for many individuals due to residential school exposure,” says Kim Ramier, a nurse who participated in the exchange. “I have since shared my new knowledge with colleagues and feel more confident in my ability to provide culturally safe care.”

Many physicians are also sharing their perspectives, and how they’ve

adapted their own approaches after participating in learning opportunities and working with First Nation communities. IH’s medical leadership has made public commitments to cultural safety and is encouraging doctors across the health authority to be open to change.

Dr. Trevor Corneil, IH Vice President of Population Health and Chief Medical Health Officer, says, “By listening, you get to understand the patient’s story and juxtapose it with history, and ask yourself what impact that has had on their health.”

Progress is visible at IH facilities, too. Aboriginal signage and artwork has been installed at facilities throughout IH – a clear signal to all who enter that they are on traditional Aboriginal territory, and that they are welcome there.

At Penticton Regional Hospital in the fall of 2018, Syilx Nation artist Clint George unveiled a metal sculpture of an abalone shell smoke bowl, a sage grass bundle and an eagle feather.

These are the tools necessary to certain First Nations’ smudging ceremonies in which smoke purifies, protects, and heals.

While working on this sculpture, George suffered a heart attack and received care at the hospital. This spring, now recovered, the artist presented, on behalf of himself and his community, an eagle feather to the hospital as recognition of the relationship that has been built over time – one that is welcoming, trusting, and respectful.

“It all begins with relationships,” says Anderson, Corporate Director of Aboriginal Health. “When relationships are strong and trusting, and when we work together collaboratively, we can improve the health of our communities.”

The renewed Partnership Accord between the seven First Nations and Interior Health is a steadfast commitH ment to continue in this direction. ■

Brad Buie is a Communications Consultant at Interior Health.

38 HOSPITAL NEWS AUGUST 2019

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NEWS

Social workers on the front lines of care

By Emily Dawson at Hennessey quickly recognized that her social worker at St. Joseph’s Health Centre, Kate Lawton, would be giving her an unexpected gift – time and a listening ear.

Pat started seeing Lawton during the most difficult time in her life. She was caring for her father with dementia and living with excruciating neck pain due to myofascial pain syndrome. She was also dealing with unresolved grief for her son who she lost prematurely, a grandmother she nursed until her passing, and myriad other losses in her life.

“In my first visit with Kate, not once did she interrupt me,” says Hennessey.

“I was able to just let everything out. I left her office feeling like a huge weight was lifted.”

As part of her healing, Lawton asked Hennessey to write a letter to the son she lost.

“We then systematically worked through all the things that had piled up, emotionally,” recalled Hennessey.

“She is so accommodating and flexible. She’s been my saviour. The last time I saw Kate, I asked her to stand up so I could give her a big hug. I told her, ‘You are my guardian angel.’”

Across Unity Health Toronto, social workers such as Lawton provide support, connections, advocacy, and counselling to patients and residents Lawton is part of St. Joseph’s Urban Family Health Team. Much of her work is with people who are in emotional distress, which severely impairs their ability to function in everyday

P

life. This distress might result from medical or psychological reasons – or a combination of both.

“The trust they give me is an enormous responsibility,” says Lawton.

“When I see their progress or help them identify their strengths, and when I can help them identify the hope that things can get better, that’s where the real meaning is in my work.” *** On a typically busy day at the Inpatient Mental Health Unit at St. Michael’s Hospital, Ron is eager to talk about how social workers, such as Nicole Schroeder, have been supporting him.

“Nicole is great. She’s helped me a lot with my finances and community resources, she knows her stuff,” says Ron. “There have also been psychological discussions, especially helping me with boundaries and meditation.”

Schroeder is no stranger to the complex issues her patients face, and she’s grateful to work in a system where innovative and strong partnerships – both inside St. Michael’s and within the community – support and advocate for patients like Ron. “Social workers are experts in system navigation, which can be complex and intimidating structures at the best of times, never mind when people are in crisis or the worst thing in the world has just happened to them,” says Schroeder.

“It’s really about knowing the ins and outs of how people can make a really complicated social situation better.

We make connections with the right supports in the system to empower pa-

tients with the resources they need.”

Ron is now getting ready to transition back to the community.

“I’m really aware now that I have people in my life to help me, not just H people who take advantage of me.” ■

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Emily Dawson works in communications at Unity Health Toronto.

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AUGUST 2019 HOSPITAL NEWS 39

nursesknow.ona.org

Don’t let Doug Ford wreck health care.

Doug Ford’s health-care reform isn’t a plan.

It’s a wrecking ball. He’s breaking our health-care system apart with no clear idea about what comes next, leaving the hard details for everyone else to figure out. It’s a failure of leadership and an affront to the people of Ontario.

Tell your MPP, the Health Minister, and Doug Ford to stop now.