Hospital News 2018 February by Hospital News

SPECIAL FOCUS: INFECTION CONTROL Inside: From the CEO’s Desk | Evidence Matters | Ethics | Safe Medication | Careers

February 2018 Edition

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Contents February 2018 Edition

IN THIS ISSUE:

Planning makes perfect in stairwell demolition project

5 ▲ Cover story: Waging war on infections

▲ Infection Control Supplement

15 ▲ Fixing one hospital’s tube system

COLUMNS

In brief .............................6 From the CEO’s Desk ....11 Trends in Transformation . 12 Ethics .............................26 Hospital Security ............34 Evidence Matters ...........38 Safe Medication ............ 44 Nursing Pulse ................46 www.hospitalnews.com

▲ Connecting for digital health

Responses to global pandemics too slow

▲ Artwork and the patient experience

Who is eligible for the transplant wait list – and who gets left behind? By Jennifer A. Chandler and Vanessa Gruben elilah Saunders, a young Indigenous woman with life-threatening liver failure in an Ontario hospital, has been in the news because she has been refused a potentially life-saving transplant. The media has reported that she is ineligible for the liver transplant wait list due to the provincial requirement for six months of alcohol abstinence in cases involving a history of alcohol abuse. This rule has been raised in other public cases as well – with tragic consequences. Mark Selkirk was denied access to the transplant wait list, and died two weeks after being diagnosed with acute alcoholic hepatitis. Similarly, Cary Gallant was not listed this past September because he did not meet the sixmonth alcohol abstinence rule. Fortunately, the latest news suggests that the health of both Delilah Saunders and Cary Gallant is improving. But these cases raise the question of how society should allocate organs for transplant – who is included and who gets left behind? And why Trillium Gift of Life Network (TGLN) – the provincial body responsible for organ donation in Ontario – needs to revisit the wait list rules to make sure our most marginalized citizens are not excluded. A transplant is the only life-saving option available in many cases, and one that depends upon the compassion of deceased donors and their families, and, where possible, living donors. There are not enough transplants to go around. The Canadian Institute for Health Information reported that

in Canada (excluding Quebec) in 2016 there were 474 liver transplants, but at the end of that year, 329 people were still waiting, and 78 had died while waiting for a liver transplant. The unfortunate reality is that when one person in Canada receives a life-saving organ, another person will die waiting. Fairness in access is paramount for these life or death decisions. TGLN has established publicly-available criteria for who can be put on the transplant waitlist. Some factors cannot be used to exclude people. The criteria state that eligibility should be determined on “medical and surgical grounds” and should not be based on “social status, gender, race or personal or public appeal.” Other factors may exclude a person from the wait list. These other exclusions involve situations where it is believed the candidate is unlikely to survive or to be able to follow the necessary medical post-transplant regimen to safeguard their own health and the transplanted organ. For example, these exclusions rule out people who are not expected to survive five years after transplantation due to another illness, such as cancer; people with a recent history of drug or alcohol abuse; people with unstable psychiatric conditions; or those who lack social support and who are likely to have trouble adhering to the post-transplant medical regimen. There are several problems with these exclusions. First, the criteria do not exclude people on the basis of socio-economic status, but that may be happening indirectly in practice. Continued on page 7

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Monthly Focus: Gerontology/Alternate Level of Care/Home Care/Rehab: Geriatric medicine, aging-related health issues and senior friendly strategies. Best practices in care transitions that improve patient flow through the continuum of care. Programs and advancements designed to keep patients at home. Care in rural and remote settings: enablers, barriers and approaches. Rehabilitation techniques for a variety of injuries and diseases.

Monthly Focus: Gerontology/Alternate Level of Care/Home Care/Rehab: Programs and initiatives that are transforming care and contributing to an effective, accountable and sustainable system. Innovations in electronic/digital process in healthcare, including mHealth. + Annual E-Health Supplement

+ Wound Care THANKS TO OUR ADVERTISERS Hospital News is provided at no cost in hospitals. When you visit our advertisers, please mention you saw their ads in Hospital News. 4 HOSPITAL NEWS FEBRUARY 2018

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

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NEWS

Planning makes perfect in stairwell demolition project By Kate Manicom fter a year of planning and seven months of demolition, a 17-storey stairwell has been torn down at St. Michael’s Hospital in downtown Toronto, clearing the way for linking the new Peter Gilgan Patient Care Tower for critically ill patients with the existing hospital. In the process, 410 stairs and 2,317 cubic metres of concrete were dismantled. “The stairwell had to come down so that we could finish building something great,” says Michael Keen, senior director of Planning and Redevelopment. “We knew the work would be noisy and could potentially generate vibrations. We planned the project with safety and patient care as our top priorities, and as a result of collaboration within the hospital and with our external construction partners, we succeeded in completing the project safely, with minimal impacts to patients and their loved ones.” In June 2016, the hospital’s Department of Operational Readiness initiated planning with teams across the hospital. Operational Readiness’s role was to ensure that each patient had the right care, in the right space with the right equipment and technology, at the right time, regardless of construction activities. Because the stairwell was built adjacent to critical patient care areas, including the Medical-Surgical Intensive Care Unit, the perioperative floor and medical imaging, mitigation plans were established in case noise levels or vibrations were unsafe or affected patient care. Vibration monitors were placed throughout the hospital, and protocols were developed to monitor

equipment, infection prevention and control, and patient and staff safety. The hospital also acquired ear plugs and ear muffs for patients in areas close to the demolition. The Planning and Redevelopment team worked closely with the project’s contractor to find alternate demolition methods. To reduce noise and vibrations, the contractor saw-cut the staircase from the existing structure, crushed the slabs into smaller pieces, then removed them from the site using a tower crane. Once demolition started in early 2017, an operations centre was established that met twice daily to monitor progress and resolve issues quickly. Program directors and the director of hospital operations submitted daily reports to inform the operations centre of any construction issues, noise or vibrations. Over the course of demolition, the operations centre committee held 198 meetings. The hospital’s complex clinical environment also required the contractor to work flexible hours. “While demolition was adjacent to the hospital’s operating rooms, there were some challenges in managing busy periods in the operating rooms and demolition schedules,” says Catherine Hogan, program director for Perioperative Services. “The contractor worked with us to change their schedules and enable safe patient care.” With the stairwell demolition complete, the hospital is looking to its next demolition project: the Shuter Wing will come down in 2018 as part of the expansion of the new Slaight Family H Emergency Department. ■

Kate Manicom works in communications at St. Michael’s Hospital. www.hospitalnews.com

Photo by Katie Cooper, Medical Media Centre

A view from the hospital’s 11th floor, the blue strip indicating where the Cardinal Carter South stairwell previously stood.

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FEBRUARY 2018 HOSPITAL NEWS 5

IN BRIEF

Report on patient experience in cancer care he Canadian Partnership Against Cancer has released Living with Cancer: A Report on the Patient Experience. This groundbreaking report reflects the voices of over 30,000 Canadians and is the country’s largest accumulation of patient data on the experiences of people living with, and beyond, a cancer diagnosis. The report shows that while their cancer

may be well treated, many patients experience significant, and often debilitating, physical and emotional side effects of the disease that are often not being adequately addressed. To address these gaps in the cancer patient experience, the Partnership is pushing for change collaborating with provincial governments, cancer agencies and programs, and other health sector organizations to implement

40,000 Ontarians were newly started on

tools that allow patients to report details of their symptoms in real time to their doctors. Doctors can then use this information to promptly refer patients to therapists or other services where their symptoms can be managed. This information can also be used for planning at the system level to ensure services are available where they are H needed. ■

Quick facts • Up to one in five cancer patients report no one discussed different treatment options for their cancer with them. • Up to one in four report that their care providers did not consider their travel concerns when planning for treatment. • One in four report that they were not satisfied with the emotional

support they received during outpatient cancer care. • Eight in 10 report having physical challenges after their treatment ends. Increased fatigue and changes in sexual function and fertility were the biggest concerns. • Seven in 10 report having emotional challenges after treatment ends. Worry about cancer return-

ing, depression and changes in sexual intimacy were their biggest concerns. • Four in 10 report having practical challenges after their treatment ends. Returning to work and school, as well as financial problems such as paying health care bills and getting life insurance were the biggest concerns.

high-dose prescription opioids in 2016 ore than 40,000 Ontarians were newly started on high doses of prescription opioids (over 90 mg of morphine per day, or the equivalent dose of a different opioid) in 2016. This is despite evidence that those who receive prescription opioids at higher than recommended doses are several times more likely to overdose compared to those on lower doses. In addition, according to Starting on Opioids, a new report by Health Quality Ontario, the provincial advisor on healthcare quality, 1.3 million people overall were started on opioids in 2016 – at any dosage. This is a slight decrease of about 25,000 new starts, or two per cent, from 2013. “At current rates of decrease, it would take Ontario more than a decade to reach the same prescribed opioid conContinued on page 7

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IN BRIEF

Opioids Continued from page 6 sumption rates as other economically similar countries such as Australia and the U.K.,” says Dr. Joshua Tepper, President and CEO of Health Quality Ontario. “We are hopeful the intervention of initiatives currently underway in Ontario to change opioid prescribing practices will bring the rate down much faster.” The report also shows that of the 1.3 million Ontarians started on opioids at any dosage, nearly 325,000 were started with a prescription for more than seven days. Evidence tells us that initial prescriptions for more than seven days of opioids have been associated with a higher risk of long-term use. Starts of opioids, as defined in the report, are prescriptions for people who have not filled an opioid prescription in at least six months.

RELATED FINDINGS: • Canadians are the second-largest per-capita users of prescription opioids after the U.S. at over 34,000 daily dos-

es per million in 2013-2015, according to the Report of the International Narcotics Control Board for 2016. • About 44,000 healthcare professionals in Ontario prescribed opioids in 2016. • Together, family doctors, surgeons, and dentists represented 86 per cent of all new-start opioid prescriptions in 2016. • In 2016, 865 people in Ontario died from opioid toxicity, up from 366 in 2003. Although many deaths involved opioids that were obtained from street sources, opioid-related deaths have also been shown to be concentrated among patients who are prescribed opioids more often, according to Public Health Ontario. • Opioid related emergency department visits more than doubled to 4,427 in 2016 from 1,858 in 2003: Public Health Ontario. To read the full report visit: www. H hqontario.ca/StartingonOpioids. ■

Transplant wait list Continued from page 4 For example, intravenous drug use is often associated with a background of socio-economic deprivation. This same group is more likely to require an organ transplant due to Hepatitis C yet to be excluded on the basis of drug misuse. Second, the exclusion of people whose self-care abilities are compromised due to unstable psychiatric conditions or lack of social supports will disproportionately affect people living with psychiatric and mental disabilities Finally, some of these exclusion criteria leave room for considerable discretion. Stereotypes based on social status, gender and race could play into a healthcare practitioner’s conclusion that a person lacks sufficient social support to ensure adherence to follow-up care, for example. And what about evidence? The evidence is unclear on whether six months (or more or less) of alcohol abstinence is associated with post-transplant success. Evidence is also lacking on how those

living with psychiatric conditions or mental disability will fare post-transplant. Critically, we do not know how these groups would do if given adequate access to social supports, addictions treatment and mental healthcare. TGLN is launching a study this summer to evaluate the six-month alcohol abstinence rule. In our view, similar scrutiny of the exclusion of those considered unable to manage the post-transplant medical requirements due to psychiatric or mental disabilities is also sorely needed. In the meantime, transparency in the system is essential. To evaluate the impact of race, gender and disability, the public should have access to demographic information on who is included or excluded from the transplant waitlists. The province must also take further steps to promote transplant success for all Ontarians by providing these patients with adequate access to drug and alcohol abuse treatment, mental H healthcare and social supports. ■

Jennifer A Chandler and Vanessa Gruben are Professors of Law at the Centre for Health Law, Policy and Ethics, University of Ottawa and Canadian National Transplant Research Program Researchers. www.hospitalnews.com

More than half of all cancers in 2018 will be diagnosed in people ages 60 to 79 The Ontario Cancer Statistics 2018 report estimates that in 2018, 90,483 new cases of cancer will be diagnosed in Ontario and 30,574 people will die from the disease. One in two Ontarians are expected to be diagnosed with cancer in their lifetime, and the disease continues to be the leading cause of death in the province as nearly one in four Ontarians will die from it. “The collection and reporting of reliable, up-to-date and comprehensive data is a crucial step in identifying opportunities to reduce the burden of cancer in Ontario,” says Dr. Prithwish De, Director, Surveillance and Cancer Registry, Cancer Care Ontario. “It is important to present a current view of cancer in the province to help us, and our partners, effectively plan for the future using information from which we can make informed decisions, take action and measure the impact of our H initiatives.” ■

new report released by Cancer Care Ontario highlights that the greatest number of new cancer cases in Ontario in 2018 are expected to be diagnosed in people ages 60 to 79, with this age group accounting for more than half of all cancers diagnosed.

IN 2018, 90,483 NEW CASES OF CANCER WILL BE DIAGNOSED IN ONTARIO Half of all cancer deaths are expected to occur in this group as well, while more than one third are expected to occur in people ages 80 and older. However, cancer survival has been improving more for people diagnosed between ages 60 and 79 than for most other age groups.

Erica Zarkovich, LLB, LLM General Counsel, Chief Privacy Ofﬁcer and Corporate Secretary Cancer Care Ontario

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Building a senior friendly hospital By Brynna Leslie or the last five years, Dr. Lindy Kilik, neuropsychologist with the seniors mental health program at Providence Care, has been immersed in design. Dr. Kilik was part of the working group established to research and examine best practices in environmental design for seniors with dementia, with the goal of making Providence Care’s new hospital safe and welcoming for all who receive care. “Really, it’s about getting the best opportunities for our patients in the new hospital,” says Dr. Kilik. “When we look at how to have people operating at optimum levels, we know that environmental intervention, behavioural intervention is your first line of intervention and medication comes second.” With dementia, explains Dr. Kilik, the brain is always trying to make sense of what you’re seeing and figuring out how you need to react to that. The environment plays a major role in behavioural intervention as clinical and support staff work to elicit positive behaviours.

“For the person with dementia, there needs to be obvious cues,” explains Dr. Kilik. “If the function of a room isn’t clear, the individual won’t go in. So if it’s a dining room, it needs to look like a dining room. If it’s a room where you want the individual to sit down and listen to music, it has to be clear that’s the function of the space.” Dr. Kilik notes that in a recently retrofitted long-term care home where she attends to patients, referrals for intervention have gone down significantly as a result of environmental improvements. For Providence Care’s new hospital, Dr. Kilik has offered input on everything from lighting and the position of doorways to the level of gloss and pattern on the floor. “Generally in institutional settings, lighting is dreadfully poor,” says Dr. Kilik. “Many seniors already have visual impairments because of cataracts, glaucoma or macular degeneration. Add a dementia overlay to that and poor lighting can be dangerous.”

In poorly lit areas, individuals with dementia have a greater chance of misperceiving what they are seeing. A shadow in the corner can appear as a person, which may be frightening and cause distress. Poor lighting can have adverse physical repercussions as well. “A shadow line on the floor may appear as a crack,” says Dr. Kilik. “If you’re having difficulties with visual perception and you step over it, you could break a hip.” Lighting also plays a role in quality of sleep. “We know, as we age, our sleep changes, but with dementia you get less and less restorative sleep,” says Dr. Kilik. “Yet frequently in the institutional setting we have hallway lights on all night which can cause day and night confusion. We’ve put forward strategies to dim the lighting at night, remove the blue light spectrum or maybe having motion detectors.” Floors are purposely low-gloss and patternless. Gloss can create reflections or appear slippery, which can cause confusion and alter the way the

individual with dementia walks. A floor tile with dots or lines can cause the person with dementia to misperceive them as gaps or three-dimensional objects that they need to step over, or they may bend down to retrieve the object which could increase fall risk. The new hospital has been carefully designed with 10 individual bedrooms per corridor. The grouping of 10 is at the upper end of “the family model,” which offers seniors a better opportunity to become familiar with one another and create a sense of community. The 10-bedroom pod also means there are no long hallways. At one end of the pod corridor, patients come to a central nursing station. At the other end is a large window with an adjacent sitting room. The exit door is strategically recessed on the side. “One of the suggestions for environmental design is to ensure a person doesn’t get stuck,” explains Dr. Kilik. “Often a person with dementia will come to a dead end and stay there. So you want to have interesting things to draw them, cues to keep them moving.

Brynna Leslie is an Ottawa-based Communications advisor. 8 HOSPITAL NEWS FEBRUARY 2018

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NEWS Providence Care’s new hospital design incorporates best practices in environmental design for seniors with dementia with the goal of making Providence Care’s new hospital safe and welcoming for all who receive care. The window offers light at the end of the corridor. And at the other end is a clear view to the nursing station. There are no dead ends.” “With doorways, you want to cue people to go through them or not go through them,” explains Dr. Kilik. “We try to avoid having prominent exits at the end of the hallway. It’s natural for people to be drawn to a door. With dementia, one’s sense of time may be lost. If you think your spouse is coming to visit, but they come in the evening, you may be standing at the door all day and avoiding participation in activities, so we try to camouflage doors a bit.” Outdoor spaces have been a big consideration in the new hospital as well. A terrace garden off the dining room offers seniors the opportunity to grow vegetables and flowers, or to

walk freely outdoors in the fresh air. For this generation of seniors, having individual rooms in the new hospital is integral. Dr. Kilik explains that private rooms will improve quality of sleep and it also lends itself to better interactions with visitors and family members. “On a serious note, some couples would like to spend time holding

caring for seniors and individuals with dementia. “I’ve been in practice for 23 years,” says Dr. Kilik. “This has been such a wonderful opportunity to bring these environmental intervention and behavioural intervention ideas and practices to the forefront and create the optimum environment for our H seniors.” ■

hands or sitting close next to each other,” says Dr. Kilik. “In a dorm room you don’t always have the opportunity for that, or you may be embarrassed. Our need for human contact is universal and it doesn’t diminish as we age.” Dr. Kilik believes Providence Care Hospital will be seen as the gold standard for other hospitals and homes

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NEWS

Photo courtesy of CNW Group/Humber River Hospital

Left, Dr. Susan Tory, Command Centre Medical Director; Jane Casey, Command Centre Director. Right, The Command Centre is located in a 4,500 square foot space. The Command Centre includes 20 workstations, 22 LED screens. Screens display critical information generated by real-time and predictive analytics to support decision-making, trouble-shooting and process improvement.

Canada’s first Hospital Command Centre By Joe Gorman

umber River Hospital (HRH) recently opened Canada’s first hospital Command Centre built in collaboration with GE Healthcare Partners (GEHC), addressing capacity, safety, quality and wait time issues that have preoccupied hospitals across Canada. The impact of the Command Centre will be felt immediately by patients, physicians and care providers. “As North America’s first fully digital hospital with a commitment to high reliability care, our cutting-edge technology, insight-rich data and human expertise comes together through the Command Centre to create an excellent patient experience that is both timely and safe,” states Barbara Collins, President and CEO of HRH. “Ontario is a place where today’s innovative ideas are fast becoming tomorrow’s world-renowned scientific, medical and technological breakthroughs,” says Reza Moridi, Minister of Research, Innovation and Science. “Congratulations to everyone at Humber River Hospital and GE Healthcare Partners for advancing in-

THE IMPACT OF THE COMMAND CENTRE WILL BE FELT IMMEDIATELY BY PATIENTS, PHYSICIANS AND CARE PROVIDERS

novation in Ontario, and for helping deliver the best in care to patients and their families.” HRH began its digital transformation back in 2005 when planning started for the new site of the Humber River Hospital, which opened October 2015. Since going fully digital, HRH has experienced a 20 per cent increase in benefit and efficiency. Now, with the addition of HRH’s Command Centre, the hospital expects to double benefit and efficiency to 40 per cent. “Whether it be the flu season that brings with it an influx of patients to the emergency department every year, or the fact that Canada has an aging and growing population, there are always pressures, both expected and unexpected, in acute care hospitals,” says Collins. “The digital transformation and command centre are focal

points of our strategy to deal with these pressures.” “Over the next few months, the Command Centre will enable an increase in capacity equivalent to opening a small community hospital within our walls,” explains Collins. The Command Centre includes a Wall of AnalyticsTM that provides advanced real-time and predictive insight, which triggers cross-functional staff co-located in the Command Centre to take action. This team works together to synchronize care delivery activities (e.g. patient discharge), eliminate delays in care and resolve patient flow bottlenecks (e.g. transferring patients from emergency to an inpatient bed) as soon as they are detected in the Command Centre. The alerts and actions that come to life daily in HRH’s Command Centre will also provide the basis for analysis

and process re-engineering by staff throughout the hospital so that certain issues can be avoided altogether. “Humber’s Quality Command Centre is all about action in support of care-teams and patients,” says Jeff Terry, Managing Principal of GEHC Partners. “It’s an honor to serve the Humber River Hospital team. Humber River is in the vanguard of a global command center ecosystem that is creating new tools and methods to improve quality and efficiency in healthcare.” The Command Centre plan is a multi-generational roll-out that drives increased capacity, improvements to quality care, and a high reliability environment. Future phases will further enhance high reliability care and will allow the hospital to partner with the community so that more patients will be able to be cared for at home. Collins says “The Command Centre contributes to the HRH vision of working together to deliver innovative and compassionate health care in H our community.” ■

Joe Gorman is Director, Public and Corporate Communications at Humber River Hospital. 10 HOSPITAL NEWS FEBRUARY 2018

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FROM THE CEO’S DESK

Discovery and hope By Dr. Catherine Zahn 2015 report commissioned by Canada’s Minister of Science about the health of Canada’s research ecosystem painted a troubling picture. The report found that investments in fundamental science in Canada have stagnated in recent years resulting in an erosion of our research competitiveness. Canadians – including patients and providers – should pay attention to this warning as it has important consequences for the success of our healthcare system. While there are pressing and urgent care capacity issues in all areas of healthcare, our governments must have the vision and will to invest in both research and innovative care.

THERE REMAINS AN UNCONSCIONABLE GAP IN ACCESS TO MENTAL HEALTHCARE AND SUPPORTS IN OUR COUNTRY. Nowhere is this more critical than in the area of mental health. The current state of access to mental healthcare in our country illustrates the consequences of overlooking research and innovation. In 2018, we have only a nascent understanding of the complex genetic, biological and social causes of many brain disorders, including mental illness. Mental disorders remain mysterious and frightening to us – fertile ground for the prejudice and discrimination experienced by our patients, siblings, children, friends and colleagues. While there’s been a recent surge of interest in brain science, and solid investments and partnerships that have led to real progress over the past decade, mental health research is still behind research into non-psychiatric disorders. As a result, people suffering from life-threatening mental illnesses do not have the same prevention and treatment options that are available for

many non-psychiatric conditions. Research is not an economic drain, it’s an economic driver, with a substantial return on investment. Research also pays in the form of tangible clinical improvements. For example, at CAMH’s Temerty Centre for Therapeutic Brain Intervention, investigators have modified and evaluated a treatment – magnetic brain stimulation – for use in depression. For those whose symptoms don’t respond to medication and psychotherapy and the many others who abandon treatment because of side effects, this is a game changer. It’s the first new treatment for depression in decades. Research, innovation and product development are an investment in people, in populations and in the economy. They promote recovery and alleviate suffering. Recently CAMH was entrusted with a historic $100 million donation from an anonymous donor in support of our clinical research enterprise. While the gift will spur research and innovation, it’s not the end of the story. There remains an unconscionable gap in access to mental healthcare and supports in our country. Wait times for services exceed standards and evidence informed treatments like structured psychotherapy are not covered by most provincial public insurance plans. Dedicated funding for mental healthcare falls well below a proportion that mirrors the societal burden of mental illness in Canada. Our country spends approximately 7 per cent of our healthcare dollars on mental illness, behind other OECD countries that spend 10 per cent to 13 per cent. These are issues of equity and justice. CAMH joins our partners across the mental healthcare sector to demand that governments of all stripes and at all levels, close the access to care gap by investing in both care and innovation as we work to advance our understanding of basic disease mechanisms in mental illness, and create new ways to prevent, treat and cure mental disorders.

Dr. Catherine Zahn is the President and CEO of the Centre for Addiction and Mental Health. www.hospitalnews.com

Dr. Catherine Zahn As a physician, my duty of care is to individual patients. Those of us with leadership roles in our healthcare system have an additional duty of care – to patients of the future and to patients globally. We discharge the first by being excellent

clinicians. We discharge the second by being good citizens, by advocating for justice and using our influence to drive positive social change through investment that enables discovery and innovation to Transform H Lives. ■

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TRENDS IN TRANSFORMATION

Connecting Care to Home Team

Continuous improvement in connecting patients from hospital to home By Yuki Wu atients with chronic diseases require care that spans across the healthcare continuum, inclusive of care within the hospital, in the community and most importantly – in their own home. The complexity in their care leads to prolonged hospital stay and frequent hospital readmissions for these patients. The Connecting Care to Home (CC2H) program is jointly developed by the London Health Sciences Centre (LHSC), the South West Local Health Integration Network (SWLHIN) Home and Community Care, St. Joseph’s Health Care London and Thames Valley Family Health Team. It is one of the pilots under the Ontario Ministry of Health and Long Term

THE CONNECTING CARE TO HOME (CC2H) PROGRAM AIMS TO BETTER INTEGRATE CARE FOR SPECIFIC COHORTS IMPROVING PATIENT EXPERIENCE AND DISEASE TRAJECTORY, AND DECREASING OVERALL HEALTHCARE COST

Care (MoHLT), delivering care under an Integrated Funding Model (IFM). CC2H aims to better integrate care for specific cohorts that experience higher rates of ED visit and readmissions following a hospital stay, improving patient experience and disease trajectory, and decreasing overall healthcare cost. Patients who were enrolled in the program have reported positive experiences with the team and improved self-

care confidence. Overall, in the first year the program has decreased 30-day patient readmission rates by 42 per cent and reduced overall health cost by 58 per cent. At the core of the CC2H team are an in-hospital navigator, a Clinical Care Coordinator (CLCC) from the LHIN, and a Direct Response Nurse (DRN) from the designated homecare team. The team communicates with

hospital and community providers alike, provides real-time monitoring and updates, and provides personalized self-care management education to patients. Patients are provided with education materials, a 24-hour phone line that links them with the DRN, and key equipment important for their clinical indicators such as blood pressure cuffs and weigh scales. Prior to implementation, a broad team of stakeholders were engaged. The core project team, navigators, CLCCs and community providers designed alongside hospital operation leaders and physicians leaders the first “future state” process maps to guide their work. The designing of the process was extensive, with goals including appropriate patient assessment and selecContinued on page 13

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NEWS

Connecting patients Continued from page 12 tion, communication and engagement of providers in different care settings while patient is in the program and the transition to responsible physicians as patients are discharged. The planned future state included a few “potential processes” where the team was unsure whether it would work efficiently with the current system structures in place. These were identified prior to the implementation as PlanDo-Study-Act (PDSA) Topics. Measures were determined by the team and continuous data collection occurred to understand whether these processes were successful. Data were analyzed on a periodic basis at five patients, 25 patients, 50 patients so on, or every three months, whichever occurred sooner. One of the PDSA Topics is the Risk Stratification Tool used by navigators. The Risk Stratification Tool includes important clinical and care indicators that guides the navigators to understand a patient’s appropriateness for the CC2H program. After data analyses and feedback, it was found that some patients were inappropriate for enrollment, regardless of their Risk Stratification Scores. Exclusion criteria were added to address this issue. For example, severe cognitive function issue was deemed an exclusion criterion. Additional indicators were added due to the feedback these would improve the score validity for patient risk levels. Overtime, the range of risk score appropriate for CC2H admission was also expanded due to positive reductions in same diagnosis readmissions. Another PDSA Topic identified was the communication between specialists and family physicians when patients have follow-up appointments post-discharge. The planned future state included a 30 minute teleconference call between the specialist and family physician after every follow-up patient appointment within 30 days of discharge. This is especially challenging due to the time constraints from both the physician groups. With the end goal of ensuring patient experience and effective

communication between providers in mind, the CC2H team tried several processes prior to finding the optimal solution. The teleconference was changed to be a session within the patient’s appointment – this did not improve family–physician attendance and was often delayed due to in clinic wait-time. The Clinical Care Coordinator then attended the follow-up appointment with the patient – this was found to be not sustainable due to the existing clinical care coordinator workload. Finally, a process was determined that the navigator will connect with the patient prior to their follow-up appointments, and the Clinical Care Coordinator will send an upto-date note to the family physician based on their discussion with the patient after the follow-up appointment. For the process challenges that require leadership attention such as patient hospital discharge delays, the appropriate clinical operation leaders and physician leaders were engaged and they actively contributed to brainstorming sessions and were held responsible for the action items. There were also components of the processes where faster resolution was required. This was accomplished by the daily update calls between CC2H team members. On the daily update calls, team members have an opportunity to discuss any enrollment or patient progress challenges, and these challenges are quickly resolved by group decision or by relevant leaders. One of the success factors is definitely the culture of the team where everyone is a problem solver, and team members are comfortable expressing their challenges and any new ideas. The CC2H program has recently reached the second milestone of 200 enrolled patients. The next steps for the program are to further standardize the process across different population pathways (i.e. Chronic Obstructive Pulmonary Disease and Heart Failure Patients), and to expand the program to other patient populations to elimH inate waste and improve outcomes. ■

Yuki Wu, MRT(R), MBA is the Process Improvement Consultant, Clinical Redesign at London Health Sciences Centre. www.hospitalnews.com

Connecting for Digital Health By Karen Schmidt he Canada Health Infoway (Infoway) 2017 Partnership Conference was a resounding success, hosting a record number of 339 attendees who came together in Calgary, Alberta from November 14-15 to network, share experiences and Connect for Digital Health. We chose Connecting for Digital Health as the conference theme because Infoway and its partners are now focusing on making and enabling the connections that will give Canadians access to health services, and their health data, electronically. Better access means more convenient and efficient health services, such as PrescribeITTM, Canada’s new national e-prescribing service that enables a prescriber to electronically transmit a prescription to a patient’s pharmacy of choice. Better access also means providing a gateway to personal health information and support tools through things like virtual services and portals. These kinds of connections enable patients to be better informed and better able to collaborate with their care teams to improve their health and healthcare. This approach will transform the way health care is delivered, benefiting patients and their families, clinicians, health organizations and Canada’s health systems. It’s win-win for everyone. Conference delegates heard from an impressive array of national and international speakers who discussed opportunities and addressed the challenges of transforming healthcare delivery in Canada. For example: • Andrew Slater, Chief Executive Officer of Homecare Medical New Zealand, spoke about the journey to develop innovative virtual mental health services at scale in New

Zealand and how more than one million people were connected in just 16 months; • Mariann Yeager, CEO of The Sequoia Project, the leading interoperability organization in the United States, shared insights about building nationwide health data sharing initiatives, which enable exchange across disparate geographies, vendors, technologies and networks; and • Dr. Alikah Lafontaine, Medical Lead (North Zone) for the Aboriginal Health Program within Alberta Health Services, addressed the unrealized potential for digital health to impact Indigenous Peoples, and how digital health innovators, providers and regulators can align their efforts by focusing on community-based priorities. In addition, delegates heard from patients and industry experts who talked about: technologies that will support and enable connections; clinician leadership in using digital technologies; data governance; privacy; cybersecurity; medication safety and patient engagement. Members of Infoway’s Board of Directors also joined Infoway’s President and CEO, Michael Green, to talk about the next wave of health innovation in Canada. Patients were instrumental in the success of Partnership 2017. Patient Advisors Garry Laxdal and Darlene Gallant worked with Infoway from the earliest stages of planning to shape the program themes, select speakers and advise about patient scholarships. They and other patients were also active participants in the two-day program. As a result, we are proud to say that Partnership received Patients Included accreditation for the second straight year. Continued on page 14

FEBRUARY 2018 HOSPITAL NEWS 13

A session at the Canada Health Infoway 2017 Partnership Conference.

Connecting for Digital Health Continued from page 13

“Having patients here, I think, serves to remind everybody of what events like this are really all about, that patients are the focus of the whole healthcare system and everything that we’re doing,” says Colleen McGavin, a patient from Victoria, British Columbia. “I am impressed at the incredible innovation and different things that came up from everybody,” says Iris Kisch, a patient from Calgary. “The learnings were unbelievable. And I know I am proud to walk shoulder to shoulder with everybody that was there as an equal partner in healthcare.” For the second straight year, the conference was held during Digital

Health Week (November 13-19), the annual celebration of all things digital health. The week included a number of activities led by Infoway and supporting organizations, to recognize the progress we have made together to improve the health and lives of Canadians through innovative digital health solutions. Besides having a record number of attendees, the conference reached a broader audience through live webcasts of the opening keynote sessions each day. The webcasts reached 334 people, including 100 who tuned in from the Canadian Home Care Association 2017 Home Care Summit in Halifax, Nova Scotia.

The inspiring discussions that took place at the conference extended into social media platforms with the #ThinkDigitalHealth hashtag collecting 6.6 million impressions. It also included three Facebook Live videos resulting in 2,056 views. “More healthcare should look like this conference,” says Jessica Havens, a patient from Calgary. “More healthcare should involve patients from the beginning, before anything happens, and while it happens, we should be in an ongoing dialogue. Healthcare needs to become more of a dialogue, and that’s my biggest takeaway (from the conference), using digital health to create that dialogue.”

If you missed attending the conference in-person or virtually, or contributing to the conversation on social media, you can access some of the recorded sessions here, and the PowerPoint presentations online. Infoway wants to thank our generous sponsors and everyone who participated in the 2017 Partnership Conference for sharing their time, insights and experiences. Connecting for Digital Health was our goal, and we achieved it. We look forward to welcoming everyone to our next Partnership Conference, which will be held November 13-14, 2018 in Montreal, H Quebec. ■

Karen Schmidt is Director, Corporate Communications at Canada Health Infoway. 14 HOSPITAL NEWS FEBRUARY 2018

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Infection Control www.hospitalnews.com www. ww w ho w. h sp pittal alne news ne ws.c ws .com .c om

INFECTION CONTROL 2018

Improving hand and mobile device hygiene with

UV technology By Stefanie Kreibe ith mobile device usage on the rise in healthcare environments, Mackenzie Health identified the need to find an efficient solution to sanitize frequently used mobile devices, to reduce the transmission of infectious diseases. “As we move closer to opening Mackenzie Vaughan Hospital, our smart hospital in 2020, the use of mobile devices such as phones and tablets used by patients, families and healthcare providers will continue to grow. As a hospital we are challenged to keep germs out of care environments,” says Heather Candon, Manager of Infection Prevention and Control (IPAC), Mackenzie Health in York Region, Ontario. “Recent research has shown mobile devices can carry all sorts of germs and at Mackenzie Health we are always looking for innovative ways to stop infectious viruses from entering the hospital and avoiding transmission between patients.”

other hard, non-porous items. Following a surface-clean to remove any visible dirt, the technology can sanitize these common devices within 30 seconds. UV technology is not used to sanitize equipment that breaks the skin of a patient. In concert with Mackenzie Health staff, the Mi² team worked closely with CleanSlateUV to optimize the technology and helped improve their design and workflows for use within a hospital. Key insights and feedback from the pilot program helped further refine the design and application of the technology. Ultimately, the hospital has benefited from a solution that is fast, user-friendly, safe and supports its strategic priorities around delivering an excellent experience, with quality of care and patient safety in mind. “Our collaboration with Mackenzie Health’s staff and the Mi² team has been fantastic,” says Manjunath Anand, chief technology officer, CleanSlateUV. “Their feedback led to

THE MACHINES USE UV-C (SHORT-WAVE ULTRAVIOLET) LIGHT AND HAVE IMPRESSIVE RESULTS IN DESTROYING VIRUSES

In partnership with CleanSlateUV, a local healthcare innovator, Mackenzie Health with the support of Mackenzie Innovation Institute (Mi²), co-developed and implemented a unique mobile device sanitization solution for use in common areas of the hospital. Mi2’s mandate is to support Mackenzie Health’s applied innovation vision by acting as a catalyst for disruptive innovations in healthcare. CleanSlateUV specializes in Ultraviolet (UV) technology to sanitize a wide range of small non critical mobile devices such as cell phones, tablets, ID badges, stethoscopes, watches and

meaningful product design and user interface improvements, and they helped prove how valuable the technology can be to patients and visitors, not just to clinicians. This has created value for users and for hospitals seeking a one-stop solution for the problem of mobile device sanitization and personal hygiene.” Given the novel nature of the device sanitization technology, an awareness campaign on educating the public around the hazards of pathogenic bacteria commonly found on mobile devices was designed and implemented. “We were pleased to see that many patients, staff and visitors are cleaning

Rahim Khalifa, Innovation Project Consultant from the Mackenzie Innovation Institute (Mi²) sanitizes his mobile phone using the CleanSlateUV device at the Mackenzie Richmond Hill Hospital. their cell phones and mobile devices on a regular basis, when [the device] is located in convenient areas such as the hospital main lobby or while they are waiting to order a coffee,” adds Candon. “This is a good habit to practice all year-round, but even more so during flu seasons. Allowing patients and families to sanitize these items on the way into the hospital potentially prevents germs and viruses that can make already sick patients, even sicker.” “Hundreds of non-critical devices are now being cleaned by our team and visitors multiple times a day using CleanSlate,” adds Tam. “With this technology we are educating visitors and our team on the importance of properly cleaning devices to reduce the number of pathogens being innocently carried around our facility each day.” Following a pilot of the technology at Mackenzie Richmond Hill Hospital, the equipment is now stationed in the main lobbies of the hospital for use by patients, visitors and hospital staff. “Innovation is a key enabler in achieving our vision to create a worldclass health experience,” says Richard Tam, executive vice-president and chief administrative officer, Mackenzie Health. “We believe that, through pioneering projects such as the partnership with CleanSlateUV, we can

help demonstrate the value of mobile, ‘smart’, and secure communications in a healthcare environment and are looking forward to the opportunity to expand our findings for the benefit of our community.” The machines use UV-C (shortwave ultraviolet) light and have impressive results in destroying viruses including a 99.999% MRSA kill rate, 99.93% Clostridium difficile kill rate and >99.992% kill rate for Salmonella enterica, in just 30 seconds. Recently Mackenzie Health received REACH funding (Resources for Evaluating, Adopting and Capitalizing on Innovative Healthcare Technology) from Ontario Centres of Excellence (OCE), to develop a real-time hand-hygiene data collection solution using smart replenishment tracking. This project will create an on-demand hand hygiene supply replenishment process and integrate with an ‘Internet of Healthcare Things’ platform (IoHT)OM. By better understanding the four moments of hand hygiene in patient care areas through data modeling approach, Mackenzie Health aims to optimize the process of having the right hand hygiene supplies in the right place at the right time while increasing hand hygiene compliance. The project is expected to be completed by early H 2019. ■

Stefanie Kreibe,is a Senior Communications Consultant at Mackenzie Health 16 HOSPITAL NEWS FEBRUARY 2018

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INFECTION CONTROL 2018

Antimicrobial resistance surveillance in Canada By Molly Blake anadians are increasingly aware antimicrobial resistance (AMR) poses a serious national and international public health threat. The World Health Organization (WHO) recently acknowledged the dire consequences of AMR and issued a Call to Action to address escalation of AMR and associated health threats. They have warned that without urgent, coordinated action, “a post-antibiotic era – in which common infections and minor injuries can kill – is a very real possibility for the 21st century”. Recognizing the seriousness of the matter, for only the fourth time in history, the UN General Assembly addressed a health issue and convened a Special Session on AMR.

definitions for long-term care facilities. Federally, the recent release of the Pan-Canadian Framework on Antimicrobial Resistance and Antimicrobial Use provides an overarching policy framework that lays out strategic goals and guiding principles to address AMR. Investments to support AMR-related innovation and AMR research through the Canadian Institutes of Health Research, and recent changes to Food and Drug Regulations to limit antimicrobial resistance have been timely and appropriate. There are existing national programs/organizations that have

Molly Blake

also made progress on measuring the scope of AMR – which could be better leveraged to support data collection. Canada must immediately drastically improve its capacity to respond to AMR through improved tracking and surveillance of resistant bacteria and analyzing the success of our collective interventions. The federal and provincial/territorial governments, healthcare workers and administrators, community leaders, our international partners, and the public at large need to be aware of the pressing and global concern echoed H widely and act with urgency. ■

Molly Blake is President of Infection Prevention and Control Canada and is an Infection Prevention and Control Professional at the Winnipeg Regional Health Authority.

WHO HAS WARNED THAT WITHOUT URGENT, COORDINATED ACTION, “A POST-ANTIBIOTIC ERA – IN WHICH COMMON INFECTIONS AND MINOR INJURIES CAN KILL – IS A VERY REAL POSSIBILITY FOR THE 21ST CENTURY Canada has been recognized as a world leader in many aspects of health, yet we lag behind many international jurisdictions in addressing AMR. All levels of government need to work together to establish a consistent national surveillance system, with nationally-approved case definitions, to close gaps in the currently fragmented system of measurement for AMR. There are valuable frameworks, but as healthcare professionals we must stand united in pushing for funding and implementation. Significant investments are needed to support the move from a piecemeal approach, to an integrated national surveillance strategy. This will help the public by providing a comprehensive picture of AMR in Canada, and help professionals assess the efficacy of interventions. Canada needs better health human resources in this respect, and support to fight AMR across settings. www.hospitalnews.com

AMR has far-reaching implications for humans, animals, healthcare, agriculture, the environment, security, the economy and global trade. “Patients with resistant infections are often much more likely to die, and survivors have significantly longer hospital stays, delayed recuperation, and long-term disability”. The capacity of our healthcare system declines daily as care providers find themselves using additional rounds of antibiotics and resorting to less commonly used, more toxic pharmaceuticals for treatment. This is compounded by the paucity of new antibiotics in the research and development pipeline. Steps have been taken by federal and provincial governments and regional health authorities to address AMR challenges. Work has already been done, including development of pan-Canadian standardized case

FRIENDS AND COLLEAGUES IPAC Canada is a multidisciplinary professional association of those engaged in the prevention and control of infections in all healthcare settings. IPAC Canada represents its members in the pursuit of patient and staff safety and in the promotion of best infection prevention and control practices. We work regularly with other professional associations and regulatory bodies to develop guidelines. Our members come from across the continuum of care. Visit our website www.ipac-canada.org to see the many benefits and resources that are available to members. INFECTION PREVENTION AND CONTROL CANADA (IPAC CANADA) FEBRUARY 2018 HOSPITAL NEWS 17

INFECTION CONTROL 2018

Hospitals and midwives:

Partnering to meet community reprocessing needs By Amber Lepage-Monette ealthcare doesn’t just take place in hospital. It takes place where we live: both in the community, like when you get a dental cleaning, and in our homes, like when a baby is welcomed into a family. Healthcare providers who are out in the community providing high-quality care meet an important need in allowing people to live and thrive in their everyday lives, while at the same time supporting hospitals to focus on more acute patients. And while following appropriate infection prevention and control practices are a cornerstone to providing high-quality, safe care, consistently meeting rigorous reprocessing guidelines for medical devices can be challenging for community based providers who must be experts in many things.

This is where hospitals come in. Already staffed with fully accredited technicians and outfitted with equipment that can handle a high volume of equipment, hospitals are perfectly poised to fill this community need. Guelph General Hospital (GGH) is just one organization already providing this valuable service to community partners. Because they were already providing reprocessing services to other hospitals and local healthcare facilities, like Homewood Health Care, it was quite easy last year to also welcome one of their local midwifery practices on board. “We consider them to be a big part of our family at GGH and they feel like they’re part of our team as well – it’s a nice partnership,” says Jennifer Ritchie, Manager of Medical Device Reprocessing Services at GGH.

Guleph isn’t the only region doing this. Midwives at Countryside Midwifery Services (which has offices in Milverton and Palmerston) approached Stratford General Hospital about taking over their reprocessing needs. The hospital was receptive from the beginning, says midwife Mandy Levencrown. “They said ‘Absolutely!’ and had already been doing it for VON nurses and for other community based groups for years.” Though overall the transition has gone very well, Levencrown says there are some small logistical challenges. Because Countryside Midwifery has a nearly 50 per cent home birth rate and now the equipment is reprocessed elsewhere, the midwives needed to evaluate how much equipment they would need to provide seamless care while waiting to pick up the next batch. Transportation is another challenge for the midwives, especially those

Photo credit: Association of Ontario Midwives.

working at the northern Palmerston clinic. Finding a similar set-up at a site further north would ease that burden for those midwives, but for now, Levencrown says they are happy with the system in place. Centralized, hospital-based reprocessing meets many needs: it not only addresses Canadian Standards Association recommendations, but also removes the burden from time-strapped care providers while enhancing healthcare. “We have the capacity to lend our expertise to our partners in the community,” says Ritchie. “In the end, it’s a valuable service that bolsters health care provided to a wide range of H community members.” ■

Amber Lepage-Monette is a Communications Officer at the Association of Ontario Midwives. 18 HOSPITAL NEWS FEBRUARY 2018

www.hospitalnews.com

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Occupational therapist Laura Shapiro (left) and physiotherapist Rebecca Bunston (right) helped develop Tough Scrubber at St. Michael’s.

Supercharge your hand-hygiene education

Are you a Tough Scrubber? By Emily Holton

KILL PATHOGENS IN 60 SECONDS NEW Clorox Healthcare® Fuzion™ Cleaner Disinfectant CloroxHealthcare.ca

un, fast, challenging, hilarious. Is this how your staff would describe their hand-hygiene education? Try Tough Scrubber and they just might. In the St. Michael’s Heart and Vascular Program, our traditional hand hygiene interventions were feeling a bit stale. Engagement was low – and honestly, it showed in our compliance rates. We needed more than a poster. We needed a sensation! Enter Tough Scrubber, the brainchild of our program’s Quality and Safety Leaders Group. A play on the Tough Mudder concept, front-line staff go through a fast-paced, over-the-top simulation that’s tailored for their clinical area. There’s a quick quiz before they start and a quick debrief after they finish… and that’s it. The whole process takes 10 minutes or less. We’re happy to report, it was a huge hit! We’ve put together a five-minute video and toolkit (available at www. stmichaelshospital.com/toughscrubber) to help hand-hygiene champions im-

plement Tough Scrubber in their own hospitals and health-care organizations. For our staff, Tough Scrubber opened the door to a new way of thinking about hand hygiene. It’s OK to ask questions and to give your colleagues feedback – we’re all learning. Doing hand hygiene correctly can be tough, but it’s much easier when we help each other out. To date, 43 Heart and Vascular staff have completed Tough Scrubber, and our hope is that you will too. All it takes is our toolkit, 4-5 hand-hygiene leaders (to run the activity and pose as patients), an empty patient room with two beds, and the everyday equipment described in the scenarios (e.g. a wheelchair, a basin). In our Heart and Vascular Units, we’ve improved our compliance rate for Moment 1 by 27 per cent in three years. This is certainly the result of a combination of years of education, hard work and many different kinds of interventions. However our Tough Scrubber sessions truly felt like the tipH ping point. ■

Emily Holton is on the communications team at St. Michael’s Hospital. 20 HOSPITAL NEWS FEBRUARY 2018

www.hospitalnews.com

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protection through prevention

INFECTION CONTROL 2018

Waging war on New technologies join forces with proven methods of hospital infection control By Diana Swift o far, the first two decades of the 21st century have been banner ones for lethal drug-resistant superbugs – Clostridium difficile (C. diff.) vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). Add to that the spectre of viruses from Avian to Zika, with Ebola, MERS, and SARS in-between – outbreaks of which could someday tax Canadian hospitals. The statistics are troubling: an estimated one in 10 adult inpatients will have some type of hospital-acquired infection, to the tune of 220,000 cases a year, and one in 12 will get a superbug infection, These cases can entail as much as $20,000 worth of extra treatment and extended stays at an

overall annual cost of $1 billion. According to the Patient Safety Institute at least 8,000 infected patients die annually. As the war on pathogens heats up, hospitals are using updated versions of tried-and-true methods: elbow grease enhanced by dedicated monitoring and feedback to cleaning staff. But newer technology is joining forces with traditional ways in the battle against bugs. According to the Ontario Agency for Health Protection and Promotion and the Healthcare Infection Control Practices Advisory Committee, newer techniques such as ultraviolet (UV) light cleaning and disinfectant fogging techniques should supplement, not replace, standard cleaning techniques. Still there are some intriguing new options either in use or on the horizon.

(See sidebar “New weaponry in the war on infections”) In agreement is Winnipeg-based Molly Blake, President of Infection Prevention and Control Canada. “We need to make sure our basics are sound and to focus on strategies that we know work,” she says. “It’s always good to add new approaches. But resources, whether financial or human or structural, differ at different sites so new techniques can’t be applied evenly. Resources and therefore techniques are very site-specific.” One low-tech method is stepped up adherence to traditional housekeeping to reduce the reservoir of microbes. For several years, Winnipeg’s St. Boniface Hospital has been auditing cleaning compliance using an invisible gel that fluoresces under UV light to audit sur-

faces wiped with disinfectant by cleaning staff. “At first staff was shocked to see that compliance was only about 50 per cent,” says Michelle Alfa, PhD, a consulting clinical microbiologist in Winnipeg. “We tracked this for many months and found that as long as we gave the cleaning staff continuous feedback and had them come back and reclean missed surfaces, they were able to maintain compliance at more than 80 per cent. It made a big difference in the effort they made.” In another study Alfa reported that replacing a cleaner with a daily hydrogen peroxide disinfectant with 80 per cent compliance significantly reduced the rates of inpatient MRSA, VRE, and C. diff. infections. The audit approach has also been successful at the McGill University Health

New weaponry in the war on infections Microbial infighting defeats C. diff • Rival strains of Clostridium difficile use micro weapons to kill each other off and gain supremacy, and now British and U.S. scientists are engineering similar tools into a novel antibiotic agent with the potential to prevent or cure C. diff infection. Though still at the laboratory stage, the Avidocin-CD nanomachine binds to the S-layer on the bacterial cell surface and then, like warring C. diff bacteria, lethally drives a harpoon-like nanotube through the cell envelope. Canines contra Clostridium • At Vancouver Coastal Health Angus the Springer spaniel is sniffing out C. diff. in spots missed by cleaners or where recent transmission has

occurred. Whether he detects a single spot or pervasive room contamination, he quickly goes into alert mode. Let there be light! •UV light has been used for years to disinfect rooms and equipment. A relative newcomer to Canada is the LightStrike PX-UV system (Xenex Disinfection Services, San Antonio, Tex.,), a portable robotic unit that pulses UV-C light via an environmentally friendly xenon gas bulb rather than a standard mercury bulb. Studies of LightStrike have shown it can reduce infections, but its cost is relatively high, with per-unit prices, including a year’s servicing, ranging from USD $137,250 to $147,750.

22 HOSPITAL NEWS FEBRUARY 2018

•Blue-violet light can also sterilize. A new two-mode LED ceiling fixture called Indigo-Clean by Kenall in Kinosha, Wis., uses “white disinfection” while a room is occupied and provides ambient light, while an “indigo disinfection” mode provides more power without ambient light. Staff and patients can safely occupy the room during both modes, but decontamination with blue-violet light can take several hours versus minutes with UVC light. Unlike UV-C, blue-violet light does not damage rubber or plastic. •In another photic application, UVC light is taking aim at germ-dense mobile devices. Already in use at several Canadian hospitals, the CleanSlate UV Sanitizer is a compact countertop machine

that UVC irradiates cellphones, remote controls, and tablets for 30 seconds, and simultaneously reminds users to sanitize their hands. Its no-touch lid is made of antibacterial copper. The Torontobased manufacturer’s prototype device killed 99% of MRSA bacteria and C. diff. spores left on precleaned surfaces, and the next step is to see if this product can actually reduce hospital-acquired infections. The cost ranges from about $4,900 to $9,500, potentially allowing for several devices per institution. Infertile breeding grounds Sodium power • For millennia, humans have used salt to preserve food from www.hospitalnews.com

INFECTION CONTROL NTROL 2018

infections NEWER TECHNIQUES SUCH AS ULTRAVIOLET (UV) LIGHT CLEANING AND DISINFECTANT FOGGING TECHNIQUES SHOULD SUPPLEMENT, NOT REPLACE, STANDARD CLEANING TECHNIQUES

Centre in Montreal. “We do a lot of auditing using the gel and have had a hand hygiene and antibiotic stewardship program over the past five years,” says Dr. Charles Frenette, medical director of Infection Control at the McGill University Health Centre (MUHC). In other measures, MUHC’s newest addition, the Glen Site, features single rooms only to reduce patient-to-patient transmission and all rooms are HEPA-filtered. The site has a special medical device reprocessing centre and separate elevators for patients and equipment. “We’ve reduced infection with VRE and MRSA by more than 50 per cent and of C. diff. by 35 per cent,” Frenette says.

At Vancouver Coastal Health UV-C sterilization has helped reduce the microbial bioburden with a mobile RD unit that cleans bathrooms and patient rooms as well as operating rooms and endoscopy units. “We also have UVC lights embedded in the bathrooms of some single-patient rooms and some shared bathrooms, and that’s worked out very well,” says Dr Elizabeth Bryce, regional medical director for Infection Control at Vancouver Coastal Health. “Our C. diff. rates have gone down remarkably.” In a 2016 study of shared hospital bathrooms, for example, Bryce and colleagues reported a 95 per cent

reduction in surface bacteria and a 35–48 per cent reduction in airborne bacteria in a bathroom sterilized with UV-C light versus a control bathroom cleaned with standard measures. Other stakeholders are looking at refitting hospitals with microbe-resistant surfaces made of copper, salt, and sharkskin-like plastic (see “New Weapons in the War on Bugs”). These are promising but will their price be worth it? “Ultimately, you need to assess where you might need to install new surfaces versus where you might reasonably apply them,” says Bryce. “We still lack a lot of information on how they hold up, how durable they are, how they interact with our standard disinfectants – and ultimately how cost-effective they are.” Despite redoubled efforts, hospital-acquired infections will continue to occur, especially if new antibiotic development continues to lag behind drug resistance by emergent strains. According to Blake, what’s desperately needed in infection control is an

integrated national surveillance system with cross-country monitoring of infections. “Currently we have no national database that addresses trends across the country and allows us to make connections. Surveillance is very fractured and piecemeal, leaving healthcare professionals at a disadvantage in protecting the public,” she says. Pointing to gaps in inter-provincial in data sharing during the SARS outbreak of 2003, Blake adds, “A national database working with consistent definitions across regions is the next step we need to take.” But effective surveillance will require resources, human and financial, and not all healthcare facilities are equally blessed with these. In its 2017 call for a pan-Canadian framework for preventing infection, Health Canada acknowledged that “Limited resources and infrastructure, particularly in some small hospitals and rural and remote regions, may also affect their ability to participate in surveillance H programs.” ■

with surfacing highly wiith th copper cop oppe p r su urfac rffacin ing ng ha had dah hi ighly gh hly ly significant microbial s gn si gnif ific fic i an antt reduction r du re uct ctio i n in io nm icro ic cro robi ob biia all load regular rooms. load vversus ersu er s s regu su gularr room ro oo s. s.

harboured per fewer MRSA harb ha rbou rb oure re ed 94 p er ccent er e t fe en ewe werr MR RSA A bacteria ba act c er eria ia a tthan han ha n a sm ssmooth moo moo oth h ssurface, u fa ur f ce ce,, and outperformed and even an even en o uttpe perf rfor rf orme med co ccopper. p er pp er..

Diana Swift is a freelance nce writer in Toronto.

bacterial contamination. Now ion io n. N ow Edmonton-based Outbreaker tbreaker Solutions Inc. has harnessed rnessed the antimicrobial force off compressed salt, producing coverings ings for hightouch surfaces such as doorknobs, taps, bed railings, and d toilet handles. Currently under nder review by the U.S. Environmental tal Protection Agency, it’s also beingg tested in a phase 2 trial at the University of Alberta, and may be on the Canadian market by 2019. The red metal • Since ancient times copper containers have been used to preserve the quality of water, and now the red metal and its alloys are being turned to infection reduction in healthcare settings. Replacing www.hospitalnews.com

standard work surfaces with stan st anda dard rd w ork or k su surf rfac aces es w ith it h copper copp pper has been shown to reduce microbial burden in ho hospitals ospitals around the world butt so far not in Canada. One study reported that a copper surface also significantly reduced the microbial burden of a nearby non-copper surface in a phenomenon known as the halo effect). A 2015 study at the Medical University of South Carolina in Charleston reported that patients in ICUs with copper alloy surfaces had a significantly lower rate of incident hospital-acquired infections or colonization with MRSA or VRE than those in standard rooms. • Similar results emerged from a Vancouver Coastal Health pilot study, which found rooms in a transplant centre reengineered

Shark repellent •A plastic sh sheet whose shee e t wh ee whos ose os e ri rridged d ed dg texture mimicss tthe denticles on he d en nti t cl cles es o n sharkskin is beingg iinvestigated nves nv e ti es tiga gate ga ted ed as a chemical-free inhibitor of bacterial all growth. Sharklet Technologies, Inc., headquartered in Aurora, Colo., is testing an anti-adhesion surface whose diamond pattern interferes with the ability of microorganisms to take hold – just as sharkskin repels algae and barnacles. Developed to ward off adhesions on naval ships, the material is being evaluated to see if it can actually reduce infections in hospitals. In one study Sharklet

Antimicrobial decor Antim An microb crrob bia iall de deco corr co •S Surgical drapes with urgi urgi ur g cal cal dr ca d ap a pess iimpregnated mpre mp regn re egn gnat ated w ated at ith it h the iodine-based disinfectant th he io iodi d ne di n -b -bas ased as ed d issin infe nfe fect ccttan antt iodphor been tested iodp io d ho dp horr ha have ve b een ee n te test sted st ed tto o prevent prev pr e en ev entt su ssurgical surg urg rgic ical ic cal al iinfections. nfe nf ections. c One study, however, found no difference in C-section infection rates between sterilizing with an alcohol scrub plus iodophor drapes and with the scrub alone. • As for microbiocidal wall and other paints for preventing infections in healthcare settings, a 2017 review by the Ottawa-based Canadian Agency for Drugs and technologies in Health turned up no relevant data on that method.

FEBRUARY 2018 HOSPITAL NEWS 23

INFECTION CONTROL 2018

Research explains why global responses to pandemics are too slow Outbreaks during holiday periods and summer may be deadly ew research shows that political dilly-dallying delays global responses to emerging pandemics more than poor surveillance capacity. Steven J. Hoffman, professor in the Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School and his colleague Sarah L. Silverberg, conducted an analysis of the three most recent

24 HOSPITAL NEWS FEBRUARY 2018

THE STUDY FOUND THAT SLOW POLITICAL MOBILIZATION IS RESPONSIBLE FOR ALMOST TWICE AS MUCH DELAY IN RESPONDING TO PANDEMICS THAN IS INSUFFICIENT SURVEILLANCE CAPACITY pandemics – H1N1, Ebola and Zika. These were used as case studies to identify and compare sources of delays in responding to pandemics and examine what influences the length of delays. The general assumption prior to the study was that there would be quicker responses observed for more severe outbreaks or those that threaten larger numbers of people. In global disease outbreaks, there are significant time delays between the source of an outbreak and global collective action. Recent delays have been lengthened by insufficient surveillance capacity and time-consuming political processes for mobilizing action. The study found that slow political mobilization is responsible for almost twice as much delay in responding to pandemics than is insufficient surveillance capacity. In addition, the research showed there seems to be a faster response for novel diseases when U.S. citizens are infected, and when outbreaks are not during holidays. “Our findings are surprising because the world’s efforts to mitigate pandemics have thus far been focused on improving surveillance, with very little attention being placed on how to quicken political mobilization. That needs to change,” says Hoffman.

According to the analysis, the H1N1 outbreak was the least severe disease of the three pandemics and attracted the fastest global mobilization. It therefore seems unlikely that severity, especially as demonstrated by the early outbreak, dictates speed of mobilization. The analysis also found that the speed of a response is not explained by other rational factors. In global disease outbreaks, generally one would think that when more countries are affected, a global response would be faster. Yet the outbreak of microcephaly related to Zika virus contradicts this hypothesis, as the virus affected 21 countries before a pandemic was finally declared. Only three countries had H1N1 infections when that outbreak was declared a pandemic. In addition, the study found that direct impacts on U.S. citizens may be a necessary condition for a global response to a pandemic. “In all three case studies, emergencies were declared after only a few days of the first US citizens being infected,” says Hoffman. “The three pandemics, especially Ebola and Zika, were allowed to fester for long periods of time in their originating countries before the world cared.” This study is published online in the H American Journal of Public Health. ■ www.hospitalnews.com

INFECTION CONTROL 2018

Helmets and seatbelts

for the flu lanes By Kevin Reel he recent headlines about surging flu numbers have been alarming. Media in the UK are talking of the worst flu season in seven years, with 35 people dying in just one week of January – three times as many as in January 2017. Other news reports in the US rank it as the worst flu season in 15 years. Loma Linda University Medical Center set up tents outside their emergency room to help cope with the numbers. Multiple strains are circulating, with children appearing particularly vulnerable – at least 37 have died this year in the US, with that official number likely lagging well behind the actual number. The expectations are that up to five times as many children may die this year. In Florida and Texas,

FOR ME, THE BIGGEST PRESSURE TO GET VACCINATED IS SELF-IMPOSED – THE PROSPECT THAT I MAY BE THE REASON SOMEONE ELSE IS INFECTED AND MUST ENDURE SOME DEGREE OF AGONY, OR EVEN DIE

some school districts closed to reduce the spread of the flu virus. Boomers are also being hit harder than usual – more than children. Amidst the suffering and death of flu victims, the perennial discussion about vaccination raises, yet again, the issue of vaccinate or mask policies for staff in healthcare roles. I am not a fan of these. Firstly I don’t feel the evidence is of a standard that

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warrants the coercive requirement of being made to wear a mask. Without that strong evidence, my second hesitation persists: I feel these policies end up pitting individuals and colleagues against each other in unhelpful ways. Those stickers on name badges are seen as a form of virtue signalling by many, while the masks are often perceived as ‘having the aim to shame’. For me, the biggest pressure to get vaccinated is self-imposed – the prospect that I may be the reason someone else is infected and must endure some degree of agony, or even die. Vaccination is one form of added insurance against that disturbing responsibility. I accept the fact that vaccines are not entirely effective and some years they seem absurdly ineffective, and that they can produce a degree of discomfort, which I have experienced myself. There is also a minimal risk of more severe reactions. But I also know it is impossible to predict how bad the season will be each year. It is difficult to grasp the impact of the 1918 Spanish flu. That outbreak infected upwards of 500 million people – more than the population of the entire US. And it killed between 50 and 100 million – many times the population of Canada. There were arguably particular reasons for the severity of that pandemic, but we cannot predict the year we’ll encounter the next severe one. It makes little sense to me to wait to find out how severe the season will be – the risk will by

then have escalated significantly, and getting a vaccination at that point still leaves one vulnerable for weeks before it takes effect. I consider that fact that children and others die from the flu every year. We may not have direct experience of these deaths, but we are certainly well able to be aware of them. When such deaths occur nearer to us, we may never know if we have been the causal agent. It’s somewhat more likely if we haven’t had the vaccine, and especially likely if we don’t practice proper hand hygiene. However, I feel the mere possibility of being the cause is likely to haunt good people for the rest of their lives and the ‘costs’ of getting the vaccine are probably far less than the burden of that haunting. In the end, I accept the fact that these decisions are not always rational ones, and thus no amount of good reasons will shift whatever it is that prevents some people from deciding against a vaccination. So I don’t expect to change everyone’s mind. But I hope to introduce some nagging cognitive dissonance… some subtle moral uncertainty about that decision. In this way, someone might begin pondering a rethink, without risking the sort of relationship harms that I feel accompany those policies that dictate vaccinate or mask. At the very least, I use any discussion of vaccination to share agreement on the need for fastidious hand hygiene by everyone – vaccinated or not. Given those low efficacy rates some years and the unknown severity of any flu season, the duty to be mindful about that non-invasive prevention tactic never diminishes. Hand washing and vaccines are much like mandatory seatbelts and non-mandatory bicycle helmets: I hope I never need them but would not want to be without either in H case I do. ■

Kevin Reel is a Practicing Healthcare Ethicist, University of Toronto.

www.hospitalnews.com

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INFECTION CONTROL 2018

Researchers develop universal vaccine to protect against influenza A viruses esearchers have developed a universal vaccine to combat influenza A viruses that produces long-lasting immunity in mice and protects them against the limitations of seasonal flu vaccines, according to a study led by Georgia State University. Seasonal flu vaccines must be updated each year to match the influenza viruses that are predicted to be most common during the upcoming flu season, but protection doesn’t always meet expectations or new viruses emerge and manufacturers incorrectly guess which viruses will end up spreading. In 2009, the H1N1 pandemic caused 200,000 deaths during the first 12 months, and low vaccine effectiveness was also observed during the 2014-15 and 2016-17 flu seasons. A universal flu vaccine that offers broad protection against various viruses is urgently needed and would eliminate the limitations of seasonal flu vaccines.

www.hospitalnews.com

Seasonal flu vaccines provide protective immunity against influenza viruses by targeting the exterior head of the virus’s surface protein, which is hemagglutinin (HA). The influenza virus trains the body to produce antibodies against inactivated virus particles containing the head of this protein, ideally preventing the head from attaching to receptors and stopping infection. However, the head is highly variable and is different for each virus, creating a need for better vaccines. This study uses a new approach and instead targets the inside portion of the HA protein known as the stalk, which is more conservative and offers the opportunity for universal protection. In this study, the researchers found vaccinating mice with double-layered protein nanoparticles that target the stalk of this protein produces long-lasting immunity and fully protects them against various influenza A viruses.

The findings are published in the journal Nature Communications. “Vaccination is the most effective way to prevent deaths from influenza virus, but the virus changes very fast and you have to receive a new vaccination each year,” says Dr. Bao-Zhong Wang, associate professor in the Institute for Biomedical Sciences at Georgia State. “We’re trying to develop a new vaccine approach that eliminates the need for vaccination every year. We’re developing a universal influenza vaccine. You wouldn’t need to change the vaccine type every year because it’s universal and can protect against any influenza virus. “What we wanted to do is to induce responses to this stalk part of the influenza surface glycoprotein, not the head part. This way you’re protected against different viruses because all influenza viruses share this stalk domain. However, this stalk domain itself isn’t stable, so we used a very special way to make this vaccine construct with

the stalk domain and had success. We assembled this stalk domain into a protein nanoparticle as a vaccine. Once inside, the nanoparticle can protect this antigenic protein so it won’t be degraded. Our immune cells have a good ability to take in this nanoparticle, so this nanoparticle is much, much better than a soluble protein to induce immune responses.” The nanoparticles are unique because they were generated to contain almost entirely the protein capable of inducing immune responses. The double layer also better retains the protein function. To determine the effectiveness of the nanoparticle vaccine, the researchers immunized mice twice with an intramuscular shot. Then, the mice were exposed to several influenza viruses: H1N1, H3N2, H5N1 and H7N9. Immunization provided universal, complete protection against lethal virus exposure and dramatically reduced the H amount of virus in the lungs ■

FEBRUARY 2018 HOSPITAL NEWS 29

INFECTION CONTROL 2018

Hospitals should set firm policies and

launder scrubs at certified facilities By Joseph Ricci RSA recently conducted a survey on how scrubs are laundered at hospitals and healthcare facilities and the results run counter to logic. Many facilities allow workers to wear scrubs to and from the hospital, while acknowledging that this practice creates a risk of infection either in the hospital or among the general public. Some may say in response that there have been no major episodes of scrubs-related contaminations, so why all the fuss? But we believe this is shortsighted. Why wait until a tragic

event takes place to rectify standards and policies? If and when some type of contamination causes severe illness or even death, people will ask whether there was any indication that policies regarding laundering scrubs allowed unacceptable levels of risk. We believe that is the case today. TRSA conducted the survey in November 2017 among 1,400 infection prevention experts at hospitals and healthcare facilities. The key findings present a disparity between actual practices and the measures necessary to contain the risk of infection:

Successfully increasing hand hygiene compliance HOSPITAL-ACQUIRED INFECTIONS (HAIS) HÉ&#x2C6; LJ[ V]LY WH[PLU[Z LHJO `LHY HUK HIV\[ ^PSS KPL HZ H YLZ\S[ 1 9LZLHYJO ZOV^Z H KPYLJ[ SPUR IL[^LLU OHUK O`NPLUL HUK /(0Z ;OLYL HYL THU` YLHZVUZ PTWYV]PUN OHUK O`NPLUL PU OLHS[OJHYL MHJPSP[PLZ PZ JOHSSLUNPUN HUK VUL VM [OLT PZ HJJ\YH[LS` TVUP[VYPUN JVTWSPHUJL [V WYV]PKL [OL MLLKIHJR ULJLZZHY` [V KYP]L JOHUNL ( Z\JJLZZM\S OHUK O`NPLUL WYVNYHT PUJVYWVYH[LZ [OLZL [OYLL LZZLU[PHS LSLTLU[Z! HJJLZZ [V LÉ&#x2C6; LJ[P]L WYVK\J[Z" VUNVPUN [YHPUPUN HUK LK\JH[PVU" HUK HJJ\YH[LS` TLHZ\YPUN HUK YLWVY[PUN JVTWSPHUJL YH[LZ MVY MLLKIHJR ;YHKP[PVUHSS` KPYLJ[ VIZLY]H[PVU OHZ ILLU [OL WYPTHY` TL[OVK MVY TVU P[VYPUN OHUK O`NPLUL HS[OV\NO P[Â»Z ^LSS RUV^U [OH[ [OL KH[H NLULYH[LK PZ Ã&#x2026; H^LK 9LJLU[ PUUV]H[PVUZ PU LSLJ[YVUPJ OHUK O`NPLUL TVUP[VYPUN UV^ OH]L L]PKLUJL KLTVUZ[YH[PUN [OH[ LSLJ[YVUPJ TLHZ\YLTLU[ JHU IL H ]HS\HISL HZ ZL[ PU HJJ\YH[LS` TLHZ\YPUN OHUK O`NPLUL WLYMVYTHUJL NP]PUN THUHNLYZ [OL YLSPHISL KH[H [OL` ULLK MVY YLHS Z\Z[HPULK WLYMVYTHUJL PTWYV]LTLU[ The DebMed Electronic Hand Hygiene Monitoring System has been clinically proven to increase compliance and reduce HAIs.2 ;OL Z`Z[LT PZ HISL [V JHW[\YL VM HSS OHUK O`NPLUL L]LU[Z HUK WYV]PKL HJJ\YH[L YLHS [PTL KH[H IHZLK VU [OL 4VTLU[Z MVY /HUK /`NPLUL 4VYL OVZWP[HSZ HYL KPZJV]LYPUN [OPZ ZPTWSL YLSPHISL ^H` [V IVVZ[ OHUK O`NPLUL WLYMVYTHUJL HUK PTWYV]L WH[PLU[ ZHML[` 1 http://www.patientsafetyinstitute.ca/en/Topic/Pages/Healthcare-Associated-Infections-(HAI).aspx 2 Kelly JW, Am J Infect Control 2015:43:900-3.

30 HOSPITAL NEWS FEBRUARY 2018

EVEN NON-SURGICAL SCRUBS CAN PRESENT A RISK OF INFECTION WHEN WORN INTO AND OUT OF THE HEALTHCARE ENVIRONMENT â&#x20AC;¢ At your facility, are employees allowed to clean scrubs at home? Yes: 54 per cent â&#x20AC;¢ At your facility, are employees allowed to wear scrubs into the hospital prior to beginning work? Yes: 60 per cent â&#x20AC;¢ Do you believe that wearing scrubs into the hospital facility from home presents an infection or contamination risk to patients? Yes: 79 per cent â&#x20AC;¢ Do you believe that wearing scrubs home from the hospital presents an infection or contamination risk from the hospital to those outside/general public? Yes: 86 per cent Further, while nearly three-fourths of those surveyed have a policy in place regarding laundering scrubs, those policies varied by job function; and more than one quarter had no policy in place at all. The survey addresses perceptions and policies regarding the likelihood that even non-surgical scrubs can present a risk of infection when worn into and out of the healthcare environment. In 2012, the Journal of Public Health and Epidemiology published a study of nursesâ&#x20AC;&#x2122; uniforms in a Washington state hospital by University of Michigan and University of Washington researchers. They confirmed this is a noticeable risk. They found MRSA and four other bacteria on nursesâ&#x20AC;&#x2122; uniforms at the end of a work shift, with MRSA surviving on some uniforms after 48 hours.

The studyâ&#x20AC;&#x2122;s authors concluded that their researchâ&#x20AC;&#x2122;s most scientific important contribution was supporting and building on previous research that healthcare providersâ&#x20AC;&#x2122; uniforms can be vectors that spread infections not only within hospitals, but also potentially within communities. They also pointed out that the United States has lagged other countries, including Canada and the United Kingdom, in mitigating this problem. But even taking soiled uniforms home in a bag to wash them there (not wearing them in public) is often problematic. As reported in a TRSA webinar in October, in 2014, researchers from De Montfort University, Leicester, England, surveyed 265 hospital staff at four hospitals and found that 49 per cent of them didnâ&#x20AC;&#x2122;t wash their uniforms at the recommended 60Â°C (140Â°F) temperature. Many staff are failing to follow other guidelines for cleaning their uniforms (possibly increasing the risk of spreading healthcare-associated infections) such as failing to wash their uniforms separately from other clothes (40 per cent of staff). Evidence of increased risk was presented in November 2017 when the De Montfort research team published microbiological research on the effect of low temperature laundering and detergents on the survival of E. coli and S. aureus on textiles used in healthcare uniforms. This study showed that most of the microorganisms are re-

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INFECTION CONTROL 2018

moved at 40°C (104°F, a home washing temperature), but those cells still remaining may have the potential for cross-contamination to other textiles in the wash and further contamination to the clinical environment and patients. The best solution to achieve negligible risk: professionally launder all scrubs at facilities properly certified to reduce infection. Consistency in and enforcement of washing policies would be a step forward, but still inadequate, as healthcare workers would still be seen in scrubs in public. TRSA’s 2015 surveys of consumers and industry customers indicated an overwhelming segment of both the public and healthcare decision makers agree that lab coats, scrubs, gowns and other garments laundered by linen and uniform services are cleaner and more hygienic:

• 82 per cent of healthcare facility decision makers feel rented lab coats, gowns, scrubs and uniforms are more hygienic • 83 per cent of consumers say a professional launderer provides a cleaner lab coat vs. workers cleaning those coats themselves • 68 per cent of consumers are concerned when seeing medical professionals wearing scrubs outside of a medical facility The Washington researchers pointed out in 2012 that because so much research had already pointed to the need to stop public wearing and home washing of scrubs, the only question left to answer was just how extensive this problem had become. TRSA’s recent survey provided that answer. So it’s long, long past the time for eliminating these risky H practices. ■

Joseph Ricci is President and CEO, TRSA

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FEBRUARY 2018 HOSPITAL NEWS 31

INFECTION CONTROL 2018

Synthetic virus to tackle

antimicrobial resistance he National Physical Labrorary (NPL) and UCL (University College London) have engineered a brand new artificial virus that kills bacteria on first contact, as published in Nature Communications. Antibiotic resistance has become an ever-growing global challenge,

with more than 700,000 people across the world dying from drug resistant infections every year. As a result, antibiotic discovery has fallen well behind its historical rate, with traditional discovery methods being exhausted. NPL is addressing technology and innovation challenges in response to this, including support

Re-Thinking HAI Prevention By Barry Hunt, President & CEO, Class 1 Inc. :HÂˇYH OHDUQHG D ORW LQ UHFHQW \HDUV DERXW WKH LQWHUDFWLRQ RI SDWLHQWV DQG VWDII ZLWK WKH SK\VLFDO HQYLURQPHQW ,QYLVLEOH EDFWHULD YLUXVHV DQG IXQJL WUDYHO OLNH VZLUOLQJ VQRZĂ DNHV WKURXJK WKH DLU ODQGLQJ DQG DFFXPXODWLQJ RQ VXUIDFHV &OHDQ ORRNLQJ KRVSLWDO VXUIDFHV W\SLFDOO\ PHDVXUH &)8 FP RU PRUH RI EDFWHULDO FRQWDPLQDWLRQ $W WKLV OHYHO WKHUH LV D FKDQFH EDFWHULD ZLOO EH WUDQVIHUUHG WR KDQGV RU FORWKLQJ ZLWK HYHU\ WRXFK DQG FOLQLFDO VWDII WRXFK DQ DYHUDJH RI REMHFWV ZLWK HDFK SDWLHQW YLVLW $W SDWLHQW YLVLWV SHU KRXU LWÂˇV QR ZRQGHU RI GLVHDVH WUDQVPLVVLRQ LQ KRVSLWDO LV E\ WRXFK 7KH SDWLHQWÂˇV ELRPH LV LQ HTXLOLEULXP ZLWK WKH URRP ELRPH ZKLFK LV FRQVWDQWO\ EHLQJ VHHGHG E\ VWDII YLVLWRUV DQG RWKHU SDWLHQWV .QRZLQJ WKLV ZH FRQWLQXH WR GLVLQIHFW WKH SDWLHQW URRP MXVW RQFH D GD\ DV ZH KDYH VLQFH WKH V %XW GRHV WKLV PDNH VHQVH" 2XU KDQGV DUH LQ HTXLOLEULXP ZLWK WKH HQYLURQPHQW :H ZRXOGQÂˇW ZDVK RXU KDQGV RQFH D GD\ ZK\ ZRXOG ZH RQO\ GLVLQIHFW WKH URRP RQFH D GD\" 1HZ WHFKQRORJ\ VXFK DV VPDUW DXWRPDWHG EXLOW LQ 89 V\VWHPV FDQ VDIHO\ GLVLQIHFW D URRP WLPHV RU PRUH D GD\ &RSSHU FRDWHG KLJK WRXFK VXUIDFHV FDQ YLUWXDOO\ ÂśPHOW WKH VQRZĂ DNHVÂˇ RQ FRQWDFW PDLQWDLQLQJ D OHYHO RI Â˛ &)8 FP $W WKDW OHYHO WKH ULVN RI EDFWHULDO WUDQVIHU GURSV IURP WR 7KHVH DUH VRPH RI WKH FRQFHSWV EHKLQG (QJLQHHUHG ,QIHFWLRQ 3UHYHQWLRQ QDPHG D 7RS :RUOG 3DWLHQW 6DIHW\ ,QQRYDWLRQ E\ WKH 3DWLHQW 6DIHW\ 0RYHPHQW

)RU PRUH LQIRUPDWLRQ VHH www.class1inc.com/engineeredinfectionprevention (PDLO eipsales@class1inc.com

32 HOSPITAL NEWS FEBRUARY 2018

for the implementation of synthetic/ engineering biology. In line with NPLâ&#x20AC;&#x2122;s approach to addressing the global threat of antimicrobial resistance by helping to develop new antibiotics, a team of researchers from NPL and UCL have engineered a purely artificial virus, which has the ability to kill bacteria on contact. This new virus is built using the same geometric principles that determine structures of naturally occurring viruses, known as polyhedral capsids. The resulting synthetic virus acts as a 20-nm spherical â&#x20AC;&#x2DC;droneâ&#x20AC;&#x2122; that, upon recognizing bacterial cells, attacks their cell walls with bullet speed and efficacy. In contrast to a traditional antibiotic, these artificial viruses tackle a bacterium as a whole, starting with the disruption of the most complex, but vulnerable part of a bacterial cell â&#x20AC;&#x201C; its membrane. This provides an advantage over an antibiotic, which must reach and hit its single target inside a bacterial cell to be effective. This action means that bacteria are less likely to become resistant to the virus â&#x20AC;&#x201C; opening the door to potentially more effective treatments of resistant bacteria. Furthermore, because such viruses leave human cells unaffected, but have the ability to infect them like viruses do, they hold promise for gene delivery and gene editing â&#x20AC;&#x201C; core capabilities for gene therapy and synthetic biology â&#x20AC;&#x201C; as well as for killing bacteria that hide inside human cells. â&#x20AC;&#x153;This work adds to the growing toolbox of engineering metrology methods

and materials being developed at NPL to realize the full potential of synthetic biology for industry and healthcare. The research may also offer long-term and creative solutions for alternative treatments of infectious diseases that are urgently needed,â&#x20AC;? says Max Ryadnov, Science Leader in Biometrology at NPL. â&#x20AC;&#x153;When we exposed bacterial model membranes to these synthetic viruses in our experiments, the results were devastating: within a few minutes, the membranes were completely destroyed,â&#x20AC;? adds Bart Hoogenboom, Professor of Biophysics at UCL. The findings pave the way for exemplar synthetic biology tools for research and therapeutic use, while demonstrating how effective innovative measurement can be in addressing real-life challenges. This study was funded by the Engineering and Physical Sciences Research Council (EPSRC), European Metrology Programme for Innovation and Research (EMPIR) and the Department for Business, Innovation and Skills (BEIS). Specialist measurements were performed at the Diamond Light Source. NPLâ&#x20AC;&#x2122;s world-leading research is also supporting the advancement of synthetic biology through a new ÂŁ7 million virtual lab to underpin the Centre for Engineering Biology, Metrology and Standards, with LGC, NIBSC and Imperial College Londonâ&#x20AC;&#x2122;s SynbiCITE. This new lab aims to improve the reproducibility of research results to help convert innovation in synthetic biology into H valuable products and services. â&#x2013; www.hospitalnews.com

INFECTION CONTROL 2018

A new perspective on the flu shot By Elise Copps or years, Thom Good didnâ&#x20AC;&#x2122;t get the flu shot. As a nurse in the emergency department at West Lincoln Memorial Hospital, he has seen first hand how serious the flu can be for vulnerable people. He knew that he should get vaccinated to help protect people with low immunity, like infants, seniors and people who are already sick. But every year, flu season came and went and he never got around to having the shot. That was until a case of flu hit close to home. Last year, Thom came down with a bad case of the flu. â&#x20AC;&#x153;It was terrible,â&#x20AC;? he recalls. â&#x20AC;&#x153;I spent one night lying on the bathroom floor.â&#x20AC;? His energy remained low for weeks and he couldnâ&#x20AC;&#x2122;t seem to rally. In the meantime, his daughter got sick.

She was only one and a half at the time, and is prone to infections. She hadnâ&#x20AC;&#x2122;t had a flu shot either and when Thomas passed on his germs, the flu hit her hard. â&#x20AC;&#x153;It was a really terrible parenting moment,â&#x20AC;? says Thom. â&#x20AC;&#x153;I brought the flu home to my daughter and she got really sick. I felt awful.â&#x20AC;? After that, Thom resolved to get the flu shot every year to protect the vulnerable people around him. This year, he and all of his family members have been vaccinated. Though infants under six months canâ&#x20AC;&#x2122;t get the flu vaccine, itâ&#x20AC;&#x2122;s very safe for babies over that age. Thom is sharing his story to help people learn that getting vaccinated against the flu isnâ&#x20AC;&#x2122;t just about you. Itâ&#x20AC;&#x2122;s about the people around you who may not be strong enough

to fight off the flu if they get sick. Every year in Canada, hundreds of people die from the flu. By getting the shot, you protecting yourself and others.

â&#x20AC;&#x153;Now, instead of thinking about why I should get the flu shot, I think about why not,â&#x20AC;? says Thom. â&#x20AC;&#x153;Why would I not want to protect the people H I love?â&#x20AC;? â&#x2013;

Elise Copps works in communications at Hamilton Health Sciences.

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FEBRUARY 2018 HOSPITAL NEWS 33

HOSPITAL SECURITY

Building a security program:

Successful staffing By Brine Hamilton

ears ago while working as a frontline security guard in a busy Emergency Department I was approached by a middle-aged man. He was seeking assistance to get his mother from his car inside to receive treatment. I promptly retrieved a wheelchair and assisted the gentlemen and his family to bring their mother inside. He was very thankful, since I had left my post I documented the patient’s name. This was on a Friday night, the first of my three shifts for that weekend. Later that weekend I was completing a morgue duty. When completing the paperwork I was stunned to realize that I was receiving the remains of the same patient. Later that weekend I also released the same person to the funeral director. The first interaction with a representative of the hospital was with me, the security professional. In a unique experience this individual literally had their first interaction and also a final send off from the hospital with me.

BEING ONE OF THE MOST VISIBLE EMPLOYEES IN A FACILITY MAKES HAVING QUALITY SECURITY STAFF IMPORTANT TO THE OVERALL PATIENT EXPERIENCE.

Frequently the uniformed security professional is often the first and/or last person an individual will interact with when visiting a healthcare facility. Being one of the most visible employees in a facility makes having quality security staff important to the overall patient experience. Aside from creating a positive impression of the organization, healthcare security staff are required to; respond to violent incidents, ensure a safe environment, have a high level of knowledge of the facility and be an effective communicator among other things. In order to hire the right individuals to staff your security program there are many factors to consider.

COST OF A BAD HIRE Direct costs The financial implications of a bad personnel decision are significant. Depending on the source referenced it is estimated that the cost of a bad hire is approximately 2-3 times their salary. These costs are attributed to absenteeism, training, equipment, recruitment, the strain on management resources and finally severance. The amounts will vary based on actual wages paid, hours required for training and specialized training as well potential litigation issues. In the instance of absenteeism the impact varies based on whether or not organizational needs require a given shift to be filled.

When this is the case often another is required to stay at a premium or overtime rate while coverage is sought. There is also in most cases a cost associated with the individual’s sick time benefits as well. Indirect costs Aside from the financial impact there are many intangible factors negatively impacting a department as the result of a bad hire. Some of these factors are more damaging in the long term than the financial ramifications because for the most part they affect other personnel. Some negative aspects of a bad hire felt by other team members include lowered morale and engagement, quality of the program, compromised safety and potential of damage to the organization’s reputation.

COMMON CHALLENGES When bad hires are many it is typically for one of the following reasons; • Urgency to hire (proper vetting does not occur) • Limited number of suitable candidates (settling) • Resource restraints (time required to vet candidates) • Lack of planning It is beneficial to be prepared ahead of time, staying abreast of the state of current staff is important. Having knowledge of immediate plans of team members to leave for educational or career advancement opportunities will help a program leader prepare for departures adequately. One of the most effective methods to prepare for such changes is to have a pool of casual employees who are willing and able to transition into any permanent roles that will become open. Having site trained staff working regularly and becoming acclimated to the environment will assist in maintaining the quality of Security staff at Trillium Health Partners.

34 HOSPITAL NEWS FEBRUARY 2018

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HOSPITAL SECURITY service and avoid large gaps in staffing. This being said it is also important to ensure that adequate casual staffing levels are maintained to achieve these objectives.

REQUIRED SKILLS As mentioned earlier the healthcare security professional must be comfortable with and adept to communicate with anyone who may present at the facility. In the healthcare field security guards must have compassion and the ability to exercise sound judgement. Policies are black and white, however many security related incidents that occur in a healthcare facility tend to fall within a grey area. Due to the nature of the healthcare environment the security professional must also be comfortable with the sight of blood, attending the morgue, walking and standing for long periods of time, able to adapt to weather conditions as well as ever–changing situations that occur. Whether a security program is staffed through a proprietary contracted mod-

el it is important to ensure staff receive suitable healthcare training. The International Association for Healthcare Security and Safety offer multiple levels of training for healthcare security personnel as an example.

SUCCESSFUL STAFFING There are three important factors to consider when staffing a security program; • Recruitment • Hiring • Training and Onboarding Recruitment Depending on the staffing model being used at your facility it is important to engage the Human Resources department. In a proprietary program it is important to make sure recruiters know exactly what is required for the position. Most HR departments use software based programs to track and vet applicants for improved efficiency. Connect with your recruiters to be certain that the vetting tools are not eliminating good candidates. In a contracted model it is a must to communicate

exactly what the expectations are for candidates in your program. Hiring Having a structured interview process in which prepared and planned questions are asked streamlines the process. This will ensure candidates are asked the same or at least similar questions, this is important when you are implementing a scorecard (which I highly recommend). It is generally good practice to have a second person conducting interviews, especially when there are a lot of interviews scheduled. This is helpful when reviewing applicants as two people will generally recall different aspects of the recruitment process. This will also make the process a more objective one. Training and Onboarding Hiring good candidates is only the beginning of the process, sufficient training and onboarding must take place. Without proper training and onboarding a good hire is not properly mobilized to be successful in your organization. This can result in quick

turnover or poor performance. It is important to have a structured training process. At the conclusion of training an employee should feel comfortable assuming their new role with limited assistance and supervision. Another important element is the onboarding of new staff. A structured onboarding process should ideally ensure; • Employees are trained to meet the requirements of the job • Employees have access to necessary resources • Employees have a good idea of what to expect • Employees have a means of comfortably asking the “dumb” questions Following these steps will help you successfully staff your security program. Staffing is an important element of a security program as your frontline staff are a direct reflection of your organization. As the most recognizable staff in a healthcare facility it is important to have the right people in place to represent both the security program and the H organization. ■

Brine Hamilton CHPA, is Coordinator, Security Operations at Trillium Health Partners and Chairperson, Ontario Chapter, International Association for Healthcare Security & Safety.

NEWS

Using Lean principles to fix one hospital’s tube system By Carly Baxter f you think about it, hospitals’ pneumatic tube systems are pretty cool. Speedily transporting drugs or specimens through hidden pipes, getting them to their intended destinations quicker than any human can. Awesome. But at Belleville General Hospital (one of four hospitals that comprise Quinte Health Care in south/central Ontario), the tube system wasn’t always quick and it wasn’t particularly awesome. Why? Departments didn’t have tubes when they needed them and they’d spend a frustratingly long time calling or visiting other departments, trying to track one down.

A unit communication clerk puts a tube back into Belleville General Hospital’s tube system to be automatically redistributed where it’s needed.

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36 HOSPITAL NEWS FEBRUARY 2018

WITH ABOUT 800 TUBES GOING THROUGH THE SYSTEM DAILY, THE INITIAL AUDIT REVEALED THAT ABOUT 500 TIMES A WEEK, SOMEONE DIDN’T HAVE A TUBE AVAILABLE “We never had a tube when we needed one,” says Jean-Anne Hounslow, Team Leader, Endoscopy. “We would hoard them just to make sure we had one when we needed it.” Recognizing there was a problem, a group of directors and managers chose to apply their Lean learning by taking on the daunting task of fixing what ails the tube system. They completed an A3 and SIPOC and collected data by “going to gemba.” They asked front line staff about their needs and how of-

ten they are without tubes when they need one. With about 800 tubes going through the system daily, the initial audit revealed that about 500 times a week, someone didn’t have a tube available. The team determined a baseline number of tubes that each of the 28 tube stations should have and then engaged with the manufacturer to optimize the operation of the system. Using programming capabilities that had not been implemented previously, they programmed the system to automatically distribute tubes where they’re needed, taking guesswork out of the equation. All staff have to do is put the tube back in the system and press “redistribute.” “With our Lean process improvements we aim to make it easy for staff to do the right thing and difficult to do the wrong thing,” says Viviane Meehan, Process Improvement Coordinator. Four months after implementing the automated system, people have a tube when they need one 90 per cent of the time. And the team is continuously doing audits and adjusting as needed. “The change has been wonderful,” says Michelle Carlisle, a communication clerk on one of the nursing units. “It’s really rare that we’re calling other units to look for tubes, whereas that was constant before. We no longer live in fear that we’re going to run out.” “The solution was always assumed that we need more tubes, but that wasn’t the problem – we just needed to organize what we have,” says Jeff Hohenkerk, Vice President. “That’s what Lean is all about – working smarter to solve problems, thereby making our jobs easier and ultimately improving H patient care.” ■

Carly Baxter is a Communications Consultant at Quinte Health Care.

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NEWS

Artwork

and the patient experience

By Elise Copps hen plans for Hamilton Health Sciences’ Ron Joyce Children’s Health Centre began, designing the building to enhance patient experience was a top priority. The facility provides services across the life span but caters primarily to children and youth. It houses programs for mental health, autism spectrum disorder, developmental paediatrics, rehabilitation and prosthetics and orthotics. It was important to care providers that patients and families visiting the site felt welcomed and inspired. The Ron Joyce Children’s Health Centre Art Advisory Committee was formed to develop an art program for the site that would support these goals. “Research shows that art can reduce stress and create emotional connection,” says Marsha Newby, clinical leader of the Child and Youth Mental Health Program at Ron Joyce and chair of the Art Advisory Committee. “It can offer a positive distraction, and it’s an opportunity to spark discussion. That’s why we felt it was important to include high quality art in the design of our space.” In consultation with the community and made possible by donor funding through the Hamilton Health Sciences Foundation, the committee curated a collection of more than 40 artworks. The pieces range in scale, medium and style with a focus on works by Hamilton based artists. Roughly half of the pieces in the collection are local, with the remainder from artists in Toronto, Montreal, Vancouver and the United Kingdom.

Some large scale works in the collection have become centrepieces of the space. ‘Why? Because’ a hanging installation of planets and stars is suspended from the 4th floor ceiling of the building and is visible from the balcony of each storey. A city scape built of 550,000 LEGO bricks located in the Prosthetics and Orthotics Department has become a popular stop for patients and clinicians at the end of an appointment. “I often hear from colleagues who offer to show their patients the LEGO city after an appointment,” says Newby. “It gives them something to look forward to, makes the visit memorable, and builds a stronger patient-provider relationship.” The building opened in 2015, but the Art Advisory Committee’s work continues. The team regularly explores how to make the artwork more accessible to patients and families. Through Hamilton Health Sciences Foundation, they continue to invite donor funding in an effort to source new works to add to the collection, and ultimately hope to research how the H artwork affects patient experience. ■

Photo courtesy of Mike Lalich

An example of the artwork at Ron Joyce Children’s Health Centre.

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FEBRUARY 2018 HOSPITAL NEWS 37

EVIDENCE MATTERS

An innovation in cancer treatment: Do we need proton beam therapy here? By Barbara Greenwood Dufour here has been a lot of interest lately about a newer type of radiation therapy for treating cancer. Called proton beam therapy, or PBT, this treatment is thought to be a safer alternative to conventional photon therapy. Whereas a beam of photons directed at a tumour can also damage the healthy tissue around it, a proton beam is said to deliver more of its energy to the tumour, sparing the surrounding tissues. Reducing the “collateral damage” from radiation is an important consideration, especially when the tumour is close to critical tissues, such as the spinal cord and the brain, or in children, who are more sensitive than adults to radiation and therefore are at a higher risk of long-term side effects, including the development of secondary cancer.

SOME CANADIAN CANCER PATIENTS ARE BEING REFERRED TO PBT FACILITIES IN THE U.S. Currently, Canadian patients are referred to facilities in the US for the treatment because, with the exception of a specialized research facility in Vancouver that uses PBT to treat intraocular melanoma, the technology isn’t available in Canada. Should it be, or should patients continue to be sent out of country for treatment? This question is important to consider carefully given that PBT is a very expensive technology. Constructing a PBT centre can cost from US$25 million to US$200 million, depending on the size and capacity of the facility. To help answer the question, CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – recently conducted a health technology assess-

ment of PBT. The CADTH review assessed the clinical effectiveness of the therapy and its associated harms compared with other types of radiotherapy. Is it effective and is it really safer? The evidence suggests that PBT, alone or in combination with photon radiotherapy, might be as effective as other types of radiotherapy to treat most types of cancer. In terms of safety, PBT might be safer than other types of radiotherapy for some cancers but

not for others. The evidence is limited, so we’re not sure. PBT is still a fairly new technology; therefore, there aren’t enough high-quality research results available yet to understand the benefits or harms of the treatment. As mentioned previously, because the technology looks like it could be a promising option for treating certain cancers, some Canadian cancer patients are being referred to PBT facilities in the US. There have been, how-

ever, several recent news stories that describe the hardship experienced by patients and their families when they have to travel far from the familiarity of their own country to receive PBT. To find out what the evidence says about the perspectives and experiences of patients who travel out of country to receive PBT, CADTH conducted a review of the available research on this topic as part of the health technology assessment. The literature CADTH identified found evidence suggesting that travelling to and staying away from home at a PBT centre is challenging in terms of being in an unfamiliar place and away from family. However, it also reveals a more nuanced picture of the upheaval, with many patients and the family members accompanying them finding some benefits in being in a new environment and being able to better focus on treatment and care. Would Canadian patients benefit if a PBT facility were to be installed in Canada? Given the country’s vast geography, significant travel and relocation would be less for some patients but would still be required for many. Therefore, the experiences of patients and the people who accompany them for treatment are likely to be similar whether they are treated from within or outside the country. And, until there is more and better research available on the clinical effectiveness of PBT compared with other types of radiotherapy, it’s unclear whether the treatment they could receive at a PBT centre would be better than the conventional treatments that are already available closer to home. Careful consideration of all the factors – such as cost, effectiveness, and patient experiences and perspectives – can help when making decisions about whether to establish PBT in Canada. If you’d like to learn more about CADTH and its review of PBT for the treatment of cancer, visit www.cadth. ca. You can also follow us on Twitter @CADTH_ACMTS or speak to a LiH aison Officer in your region. ■

Barbara Greenwood Dufour is a Knowledge Mobilization Officer at CADTH. 38 HOSPITAL NEWS FEBRUARY 2018

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NEWS

Green health leaders

advancement towards sustainability By Dan Ritchie ccording to the Lancet Commission on Climate Change, “Climate Change is the biggest global health threat of the 21st century.” This means that healthcare facilities will need to play an increasingly significant role in managing and reducing the impacts care delivery has on climate change. The Canadian Coalition for Green Health Care (CCGHC) has been assisting healthcare providers to address these challenges for the last two decades. One of CCGHC’s newest programs is the Green Health Leaders Initiative (GHLI). The GHLI has a vision to “engage senior health executives, board members, medical staff, corporate sustainability leads, governments, associa-

tions and industry in a movement to improve climate change resiliency and environmental stewardship in Canadian healthcare”. Through this, CCGHC reaches out to a broad range of stakeholders that are determined to create a more environmentally-sustainable healthcare system. Issues that leaders in Canada are already having to face include: increasingly severe weather events that are causing damage to buildings, the need for business continuity, loss prevention and cost reduction as a result of storm damage, carbon pricing and other new regulations. Overall, there is an increasing public expectation that healthcare organizations shift towards environmental stewardship. Neil Ritchie, a seasoned healthcare

executive, has been leading this initiative on behalf of CCGHC. In June 2017, CCGHC along with HealthCareCAN, the Canadian College of Health Leaders, and Synergie Santé Environnement, held their inaugural GHLI reception in Vancouver. This interactive gathering included engagement with senior healthcare leaders and industry professionals and brought private, non-profit and government representatives together to discuss what sort of leadership is required from health care to improve the sector’s sustainability. ”We found a lot of enthusiasm for sharing ideas and an interest in continuing the dialogue” says Ritchie. The session identified key barriers and enablers that impact an organizations

ability to move towards environmental sustainability. Key enablers for healthcare providers include information sharing and the definition of targets. While in contrast, having competing priorities and lacking financial support can act as barriers to establishing environmentally sustainable policy and practices. On December 11th, Ritchie led a national webinar on behalf of the GHLI and in partnership with the Canadian College of Health Leaders. The webinar, titled “ Lead, Follow or Get Out of the Way of the Tornados,” provided an overview of the relationship between health and the environment and built the case for health leaders becoming more potent champions for the environment.

NEWS

Benefits for becoming involved with the Green Health Leaders’ Initiative include gaining skills, tools and knowledge to help shape environmentally sustainable policy. The GHLI has six major program components that include: Green Governance, Climate Change Resiliency Mentoring, Green Hospital Scorecard, Green Health Leaders Forum, Green Health Leaders Guide and clean tech procurement. Both Climate Change Resiliency Mentoring and the Green Hospital Scorecard (GHS) are free programs that are open to healthcare providers throughout Canada. The Climate Change Resiliency program gives leaders access to CCGHC’s “Health Care Climate Change Resiliency Toolkit,” a resource that helps hos-

“CLIMATE CHANGE IS THE BIGGEST GLOBAL HEALTH THREAT OF THE 21ST CENTURY” pitals self-assess their climate change preparedness level, then adapt to severe weather events and establish climate change adaptation policy in their facilities. Climate Change Resiliency program benefits received by participating organizations are valued at approximately $15 000. Currently entering it’s fifth year, the GHS is a free sustainability benchmarking tool for healthcare providers.

Healthcare leaders submit data on five major categories including energy, water, waste, pollution prevention and leadership and the data is then used to generate a physical scorecard that outlines strengths and areas of improvement for participants. Once submitted, all data will become confidential and not shared with third parties. Participating green health leaders are given a report that outlines their facilities systems and how they compare against their peers. Having a concrete metric to measure sustainability is essential in developing green initiatives and policies, and tracking progress. Participation in this year’s scorecard is open until February 28th, 2018. If your site is interested in taking part please contact dan@greenhealthcare.ca.

In 2009, the Coalition and a number of healthcare professional associations published a “call to action”. Signatories called “on all healthcare organizations to pledge to minimize the negative impact of their activity on the environment and to seek solutions to existing barriers.” The GHLI aims to help individuals minimize their negative impact and overcome the barriers to sustainability. Senior leaders from the healthcare sector are invited to join an advisory council for the Green Health Leaders’ Initiative. If you are interested in learning more, please visit http:// greenhealthcare.ca/ghli/ and contact the GHLI lead, Neil Ritchie at H neil.ritchie@greenhealthcare.ca. ■

Dan Ritchie, B. ESST is Manager of Sustainable Programs at the Canadian Coalition for Green Health Care. He can be reached at dan@greenhealthcare.ca

March Edition 2018

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FEBRUARY 2018 HOSPITAL NEWS 41

NEWS

Creating culture: Lessons learned from the journeys of top performers By Sonia Jacobs and Jennifer Volland ulture. It’s one of the hardest things for organizations to articulate, and it’s always unique in top performers. Everyone wants to be part of a thriving organization, yet the essence of what goes into creating the optimal organizational culture, and how all the different pieces fit together, can seem a mystery. However, once established, a vibrant culture goes a long way toward making your organization an environment where people want to work, and one that fosters patients’ and their loved ones’ confidence and trust. Organizations can always find improvement opportunities, but it all goes back to the underlying rule: culture is key. Working with organizations across the United States and Canada, NRC Health continually identifies top performers, their best practices, and the

factors that make these organizations unique. While healthcare often undergoes change and times of turbulence, certain aspects of top-performing organizations are always embedded into the way work is successfully performed. It starts at the top. This means giving people the supportive space and resources to do their jobs, and focusing on a purpose that everyone can align with and understand in terms of how it relates to their day-to-day work. Administrators, middle management and staff all place the patient first—and both in words and in actions, upper management in these organizations model responsibility for meeting patient needs. Every opportunity for an interaction matters. If a chance to communicate with someone is missed, there may not be another chance. Each patient has a unique set of requests; everyone owns

responsibility for addressing the patient’s experience. When members of staff or management are in a patient’s room, they are tasked with putting aside any activity outside the patient’s door and responding in the moment. Space is created to make things happen. In addition to focusing on key initiatives and modeling excellence from the top down, top performers equip their leaders with the skills and resources they need to lead their teams. To do this effectively, they regularly assemble to learn from each other, share successes, and hear about new projects or services. An example of this is the incorporation of the process of executive-leadership rounding into executive meetings as an agenda item, which helps colleagues become comfortable rounding as clinical and non-clinical leader dyads and report-

ing back to the larger group with any discoveries or learnings. It also allows leaders to understand what’s happening in other areas, positively recognize staff they may not encounter regularly, and look at processes from an outside-in perspective. Expectations are clear and aligned within the organization. Not only do senior managers set expectations in high-performing organizations, they also clearly articulate those expectations to their staff. Behavioral standards are often adopted to remove any ambiguity about how to treat others from the very beginning, starting with the hiring process, reinforced through orientation, and sustained through recognition, modeling, and holding individuals accountable for their own performance and for the organization’s mission, vision, and values. Continued on page 43

Sonia Jacobs, is VP Canadian Partnerships and Jennifer Volland is VP Program Development at NRC Health. 42 HOSPITAL NEWS FEBRUARY 2018

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NEWS

Continued from page 42 All levels within the organization are part of a data-driven culture. Although some processes work better than others, sometimes even the best performance isn’t good enough – on any day. Recognizing this, top organizations use data to drive decision-making in a way that is responsive to specific patient needs and continues to build the patient-provider relationship over time. Data is shared in leadership, multi-disciplinary, and staff unit meetings; visible on the patient units; communicated as part of daily staff huddles; incorporated into strategic priorities and the overall direction of the business; and interwoven into the fabric of the organization. Goals are clear, with well-defined targets for achievement, and staff are able to articulate the initiatives that are being conducted in their areas. When decisions are made, leadership incorporates the voice of patients and their families into every facet of each decision by obtaining initial feedback and continually receiving input through focus groups, patient experience surveys, committee work, and advisory councils. Patients and their families are involved throughout the entire improvement process, ensuring a greater depth of understanding of the issues from their perspective and full engagement in solution-finding. While there are multiple factors that contribute to the uniqueness of top performers, each one starts with taking personal accountability and implementing decisions effectively throughout all levels of the organization. In a time of dwindling resources, these tactics require no additional monetary spend – just a commitment to a culture of excellent service delivery resulting in positive patient experience and outcomes. Learning from top performers, healthcare leaders, managers, and staff can advance the quality of care and services delivered, the experience of their patients, and even clinical outcomes. While culture can seem nebulous and difficult to articulate, there are clear themes that start to emerge in top-performing organizations that foster a vibrant and healthy culture, even H during times of change. ■ www.hospitalnews.com

How nurses can fight the opioid epidemic By Michael Wong ith the U.S. and Canada in the throes of an ‘opioid epidemic’, much of the policy making has focused on stemming the rate of prescription practices. In many ways these efforts are working; a recent Global News report revealed that the total number of people prescribed opioids in Ontario remained stable, with an 18 per cent decrease in total opioid volume of 2 years. In the U.S., a CDC report found that opioid prescriptions fell by the same amount (18%) from 2010 to 2015 but with high variability from county to county. These are promising first steps, but the reality is that clinicians continue to battle an increase in opioid-related deaths. In 2014, 2015 and 2016, the B.C. government identified 366, 513, and 922 illicit substance overdose deaths, respectively, demonstrating an exponential increase in overdose-related fatalities. Moreover, opioid-related harm is not limited to ‘street-level’ overdoses. Use of opioids have far-reaching risks that extend from safe use in-hospital to ripple effects throughout entire communities. This places clinicians in a unique position to affect positive public health change on multiple levels and to prevent opioid-related adverse events and deaths from occurring both in-hospital and upon patient discharge

fessor of Surgery at Harvard Medical School and author of “The Checklist Manifesto.” To learn more about in-hospital opioid safety, please visit PPAHS here.

PREVENTING OPIOIDRELATED HARM IN HOSPITALS For many, exposure to opioids begins in-hospital. While recovering from procedures, many patients are prescribed a patient-controlled analgesia (PCA) pump to manage their pain. Upon discharge, those same patients might leave with an opioid prescription to manage their pain. Even under medically-necessary, supervised care in a clinical setting, there is a risk of opioid-related adverse

HARM REDUCTION PRINCIPLES events. Prescribing the ‘right’ amount of opioids is not an easy task. Patients react to medication differently – a fact that is an undefined factor, for example, in the opioid naive until it is too late. The situation can be further complicated by existing conditions and treatments. For hospital cases of procedural sedation and the administration of PCA pumps for patients, effective monitoring strategies are vital in detecting the early signs of opioid-related respiratory depression. For patients receiving opioids, intermittent “spot checks” to determine key physiologic metrics are not sufficient in isolation. We strongly recommend the use of continuous electronic monitoring using pulse oximetry and capnography for all patients receiving opioids. The PCA Safety Checklist released by PPAHS and developed by a panel of renowned medical experts provides recommended steps that nurses should take on initiating PCA with patients and continuing PCA administration. The expert panel included intensive care specialist and a leader in medical checklist development Peter J. Pronovost, MD, PhD, FCCM, Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient; and Atul Gawande, MD, Professor in the Department of Health Policy and Management at the Harvard School of Public Health, who is a surgeon at Brigham and Women’s Hospital Pro-

Drug-related harm, be it opioid or non-opioid, is not limited to overdoses. Blood-borne disease, soft-tissue infection and wounds, criminalization, violence, social stigma, and dependence and addiction: all of these can have far-reaching impact on people and their communities at-large. Clinicians are in a unique position to effect change on all of these aspects through the use of harm reduction practices. This can be a difficult topic to discuss. Providing care in the context of illicit substance use can raise questions for clinicians and have an impact on the provision of care. Sometimes it’s hard to remember that a core mandate of ethical clinical practice is to promote the health and well-being of the recipients of care, regardless of income, age, gender, ethnicity and other socio-demographic characteristics. Although the results of the extensive research on harm reduction are still mixed, in certain areas the benefits of harm reduction programs are significant. An overview of these benefits can be found in CNA’s discussion paper, Harm Reduction and Currently Illegal Drugs: Implications for Nursing Policy, Practice, Education and Research, which focuses on the following strategies that nurses can take for their patients: needle distribution and recovery programs, peer-based outreach strategies, overdose prevention strategies, methadone maintenance and heroin prescription, supervised injection sites and safer crack use. To learn more about how you or your hospital can employ harm reduction strategies, please visit the CanadiH an Nurses Association online. ■

Michael Wong, JD (Founder & Executive Director, Physician-Patient Alliance for Health & Safety) FEBRUARY 2018 HOSPITAL NEWS 43

SAFE MEDICATION

Not a numbers game:

Medication Safety Culture Indicator Matrix (MedSCIM) By Anastasiya Shyshlova, Jim Kong, Calvin Poon, and Certina Ho edication incident reporting is becoming a standardized and mandatory practice across many Canadian provinces. Health Canada, the Institute for Safe Medication Practices Canada (ISMP Canada), the Canadian Institute for Health Information (CIHI), and the Canadian Patient Safety Institute (CPSI) collaborate under the Canadian Medication Incident Reporting and Prevention System (CMIRPS) program to capture, analyze and disseminate shared learning from medication incidents. To determine the understanding of an organization or institution in medication safety, we often look at its safety culture, whether it is “blame and shame”, “reactive”, “calculative”, or “generative”. Patient/medication safety culture can be described as shared values, norms, competencies and attitudes towards patient safety among individuals in an organization. Quan-

THE ANALYSIS OF MEDICATION INCIDENTS CAN OFFER AN INNOVATIVE AND VALUABLE APPROACH IN ASSESSING THE PATIENT SAFETY CULTURE OF A HEALTHCARE INSTITUTION

titative data alone sets a suboptimal or likely biased foundation for medication incident analysis or evaluation as it has low sensitivity, a lack of a common denominator to quantify the rate of incidents, and is often subjected to misinterpretation when taken out of context. However, qualitative data can provide a detailed narrative and relevant accounts of the incidents. This, in conjunction with quantitative analysis, can provide healthcare professionals with a better understanding and a more complete picture of the lessons learned from the incidents. At the same time, the analysis of medica-

tion incidents can offer an innovative and valuable approach in assessing the patient safety culture of a healthcare institution. Medication Safety Culture Indicator Matrix (MedSCIM) is a novel tool designed by ISMP Canada to assess the quality of qualitative data gathered from medication incidents for a more robust evaluation of the overall medication safety culture in various healthcare settings. What is MedSCIM? (MedSCIM) was consolidated and validated by obtaining input from an inter-professional patient safety expert panel, consisting of a physician, a reg-

istered nurse, and a pharmacy technician. It is comprised of the following two dimensions (Table 1): 1) Core Event: This describes the medication incident based on completeness of the documentation submitted by the reporter; it is assigned with a rating of 1 to 3. 4 2) Maturity of Culture to Medication Safety: This assesses the reporters’ view and perceived attitude towards medication safety principles and understanding of system-based (rather than individual – or human-based) solutions; it is assigned with a rating of A to D. This tool can be used as a benchmark for transitioning health organizations from a “blame and shame” work culture with “incomplete reporting” of medication incidents to a “generative” with “fully complete reporting” of medication incidents in regards to maturity of medication safety culture H (Table 2). ■

TABLE 2: Maturity of medication safety culture is defined by colours with red as a negative, yellow as neutral, and green as a positive safety culture

44 HOSPITAL NEWS FEBRUARY 2018

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SAFE MEDICATION

TABLE 1: MedSCIM dimensions The MedSCIM tool allows for a qualitative analysis and comprehensive understanding of medication incidents to complement traditional quantitative analysis; it provides a framework for assessing the level of medication safety culture in an organization.

How to use MedSCIM Incident: Case Examples

Coversyl® 2mg was put into the system. However, it was filled as Coversyl® 4mg. The medication incident was discovered at the time of counseling. The patient was given the correct dose. During the time of filling, patient continually interrupted the pharmacist. Patient was upset that it took longer than the promised time to fill the medication. After the incident, a note was made on file. In the future, patient will be told a more accurate wait time.

Core Event

Maturity

Patient Safety Culture Level

Positive

(Generative)

Discussion: The documentation states the error clearly: the incorrect dose of Coversyl® (perindopril) was filled. As well, contributing factors such as constant interruptions were provided in the narrative description. Measures were taken to make sure the error does not happen again, such as documenting a specific note on the patients file, as well, a system change to inform staff to provide more accurate wait times to patients.

Pharmacist noticed that the strength on the hard copy was incorrect. The pharmacy staff member who made the mistake was informed about the error.

(Blame and Shame)

Negative

Discussion: The documentation stated that the error was an incorrect strength; however contributing factors leading to the error were not mentioned. In terms of maturity, a staff member is singled out and, no proactive measures were taken to prevent this error from reoccurring. As well, system based recommendations to address any potential contributing factors were unaddressed. Anastasiya Shyshlova is a PharmD Student at the School of Pharmacy, University of Waterloo, and a Medication Safety Analyst at the Institute for Safe Medication Practices Canada (ISMP Canada); Jim Kong is Program Development Manager at ISMP Canada; Calvin Poon is Pharmacy Coordinator at Niagara Health; and Certina Ho is a Project Lead at ISMP Canada. www.hospitalnews.com

FEBRUARY 2018 HOSPITAL NEWS 45

NEWS Voice-activated communications badges enhance collaboration and the patient experience by increasing staff members’ accessibility to each other and to their patients.

Nursing with a public health lens The unique skills of public health nurses are transferable to almost any area of nursing. By Daniel Punch n the shadow of St. James Cathedral’s 93-metre gothic tower, St. James Park is a welcoming patch of green among the grey concrete and orange brick of Toronto’s oldest neighbourhood. You can find a cross-section of downtown Toronto at the park. Bankers on lunch break, families towing babies and dogs, tourists, and clients of nearby homeless shelters all make use of the public space.

Hands-free technology enhances care at Runnymede

By Michael Oreskovich new voice-activated technology streamlines collaboration among clinical staff at Runnymede Healthcare Centre by enabling handsfree mobile conversations. Communication badges were recently implemented at the hospital to support efficient, coordinated care for some of the most complex patients in the Greater Toronto Area (GTA). By leveraging the new technology, Runnymede has increased its responsiveness to patients’ needs, enhanced safety and elevated the patient experience. Worn on lanyards, the badges recognize voice commands and respond by allowing staff to easily start conversations or receive incoming calls. “The technology is lightweight enough to be comfortably worn at all times, so staff are always accessible during their shifts,” says Runnymede’s Vice President, Patient Care, Chief Nursing Executive & Chief Privacy Officer, Raj Sewda. “All they have to do is say the name of a person or department into their badge, and a conversation can start.” Prior to the badges’ roll-out, clinical staff used mobile phones to communicate. Although practical, they were not ideal because staff often handle clinical instruments while treating

patients. Hands-free badges enable staff members to talk with each other without interfering with the hands-on care they are providing. The badges’ ease of use also promotes increased collaboration among members of the clinical team. This enhanced collaboration strengthens safety at Runnymede. If a patient has care needs that must be met urgently, the rapid communication facilitated by hands-free badges makes it possible for clinical team members to call others for support, or to quickly ask for additional supplies – all without ever leaving the patient’s side or interrupting their care. If the staff member they wish to reach is on their break, the system automatically sends the call to a designated back-up. To further strengthen patient safety, badges will soon be linked to the hospital’s nurse call system. “Before badges were implemented, it was only possible for nurses to be notified about patient calls through a digital display, and they had to go to the patient’s room in order to talk with them,” says Runnymede’s Director of Patient Care, Frederick Go. “Now we have the technology for notifications to be triggered on the badge worn by the patient’s assigned nurse, who will soon be able to speak with the patient

immediately after pressing their call button, to find out what they need and respond accordingly.” The badges are currently integrated with the hospital’s main phone system, providing family members with a direct line to the clinical team if they have any questions. “When a family member phones Runnymede, they’re able to access our voice-activated system, and by simply saying the room and bed number of their loved one, they can be connected to the nurse who is assigned to them,” says Go. “This provides families with convenient access to our clinical team members whenever they need it.” If discussions are confidential and not suited to an open-air conversation, staff are trained to protect the patient’s privacy by switching the badge’s mode so that it works like a conventional mobile phone. Runnymede anticipates the badges’ recent implementation will support its delivery of safe, high-quality care. “The technology vastly simplifies communication and increases the accessibility of our clinical team, which benefits patients, families and staff alike,” says Sewda. “It’s an excellent tool for strengthening collaboration and enhancing our responsiveness to H patients’ needs.” ■

THE OPIOID EPIDEMIC CONTINUES TO INTENSIFY IN TORONTO AND ACROSS NORTH AMERICA Unfortunately, you can also find an increasing number of used sharps left behind by opioid drug users. Between 30 and 50 sharps are left in the park every month, according to RN Lanadee Lampman, the St. James Cathedral parish nurse and a member of the Registered Nurses’ Association of Ontario (RNAO). The used sharps are a health concern for the local community, St. James parishioners, and the handful of homeless people who spend their days in the park and sleep on the cathedral’s porch. “We’ve got dogs and babies and vulnerable people living here,” Lampman explains. “We need to deal with this.” The solution came in the form of a big, yellow sharps disposal box. It sounds simple, but getting the box installed in the park required a yearlong campaign that engaged commuContinued on page 47

Michael Oreskovich is a Communications Specialist at Runnymede Healthcare Centre. 46 HOSPITAL NEWS FEBRUARY 2018

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NURSING PULSE Lanadee Lampman (right) and St. James drop-in co-ordinator Kathy Biasi show how their new disposal box works.

Continued from page 46 nity members and organizations, and made use of skills Lampman honed as a public health nurse more than 20 years ago. Since graduating from the University of Toronto’s nursing program in 1984, Lampman has worked in nearly every health sector. She became St. James’ parish nurse in 2013. Her time as a public health nurse in North York in the early 1990s was particularly influential, she says, noting she’s carried the lessons she learned about community engagement throughout her career, and particularly into her current role. Lampman first learned about the sharps disposal boxes at a Toronto board of health meeting in July 2016, where she was giving a deputation in support of supervised injection services. She soon joined the Toronto Needle Box Coalition, a group of concerned individuals and organizations seeking to get these boxes installed throughout the city. Getting a sharps box in St. James Park required a lot of research and advocacy from Lampman. She partnered with Toronto Public Health’s (TPH) needle exchange program to help pay for the box and ensure its contents were disposed of. She reached out to local businesses and the neighbour-

hood association to calm their fears about the “scary looking box” she planned to install. She also did “show and tell” with the people who live in the park and clients of the nearby shelters. “I’m very noisy about my box, how to use it, and what it’s for,” she says. The sharps box was finally installed on July 31, 2017. Though she still finds a few syringes in the park, more and more of them are being dropped in the disposal unit, which she checks once a month. Unfortunately, the opioid epidemic continues to intensify in Toronto and across North America. In late July, one of the “regulars” at St. James died of an overdose. And in August, Lampman used her naloxone kit for the first time to prevent another overdose on the cathedral grounds. To keep her community safe and healthy during the crisis, Lampman says she will continue to use a public health approach. She worked with TPH to educate St. James volunteers about harm reduction strategies, and is offering recovery support groups for people who have lost loved ones. “The focus on the wider community, working with groups, and connections are all things I learned from public health,” H she says. ■

Daniel Punch is staff writer for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. This article was originally published in the Sept/Oct 2017 issue of Registered Nurse Journal, the bi-monthly publication of the Registered Nurses’ Association of Ontario (RNAO).

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DID YOU KNOW?

816 Healthcare workers missed work last year

due to Workplace Violence. (WSIB EI database)

Violence in the workplace cannot be tolerated Safe workers mean better care. Letâ&#x20AC;&#x2122;s work together to reduce violence in healthcare.

workplace-violence.ca