Hospital News July 2019 by Hospital News

Inside: From the CEO’s Desk | Evidence Matters | Ethics | Long-term Care | Careers

July 2019 Edition

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Contents July 2019 Edition

IN THIS ISSUE:

Cardiac CT scan first in Canada

▲ Cover story: New cardiac ablation technique

▲ SMART tech solutions in long-term care

▲ Expanding transitional diabetics support

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

In brief .............................6 Evidence matters ...........16 Ethics .............................18 Long-Term care ...............22 From the CEO’s desk .....28

New imaging tool for diagnosing heart disease

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▲ Breath monitoring improves patient safety

Let patients help

hire your staff By Margo Twohig and Jennifer Schipper hen it comes to choosing who should staff our hospitals, it makes sense that patients or family representatives should be involved in hiring at all levels from those who clean the buildings at night to the CEO and other senior officials. After all, in a patient-centred system, who better to understand the perspective of the population being served? While it is not a given that a patient will be part of the group that chooses the CEO, senior managers or indeed any staff in today’s hospitals and other health care institutions, there is definitely a trend in this direction. It follows the growing move to meaningfully involve patients in not just their own care but in policy decisions shaping how health care will be delivered. However, there is surprisingly little data assessing the benefits of involving patients or family members on selection committees making staffing decisions in health care organizations. What published evidence does exist has been very positive. One of the only available Canadian studies was published in the Patient Experience Journal in 2015 and comes from researchers from Providence Health Care in B.C. An assessment was conducted of 30 candidates who were interviewed in a process that involved

patient interviewers, as well as health-care leaders at Providence and patients and family members who participated in the process. The researchers concluded involving patients in the interview process had a positive impact. They also noted that “the process can build momentum; an available group of trained patient and family partners (PFPs) who could be quickly engaged in hiring opportunities and thus reduce wait times for leaders requesting PFP assistance, would be beneficial.” An evaluation of patient-centred care strategies in 2012 singled out Kingston General Hospital as an organization that had included patient advisors on hiring committees and noted that the patient representative was the first to speak during the selection interview. “We intend to convey upfront to a prospective employee who they will be working for if they get the job: the patients,” said then CEO Leslee Thompson. In terms of anecdotal evidence, one patient advisor notes that “having participated on numerous selection committees … I can say that I do believe it creates a different dynamic and sends a very strong message to applicants about the role of patients and families in the organization.” Continued on page 6

Margo Twohig is a Patient and Family Advisor and 2017 Patient, Family and Caregiver winner of the Minister’s Medal Honouring Excellence in Health Quality and Safety . Jennifer Schipper is Chief, Communications and Patient Partnering for Health Quality Ontario

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NEWS

The new dedicated cardiac computed tomography (CT) scan, the first of its kind in Canada.

New cardiac CT scan first in Canada By Ann Gibbon new model of care for cardiac patients at St. Paul’s Hospital has the potential to reduce heart imaging wait times, ease Emergency Department congestion and lower the number of unnecessary hospital admissions. At the centre of the new approach is a new dedicated cardiac computed tomography (CT) scan, the first of its kind in Canada. The machine will be the key part of a stand-alone Rapid Access Chest Pain Clinic that will benefit patients with earlier prevention and life-saving treatment. “The Rapid Access Chest Pain Clinic has the potential to change the course of this disease by offering prevention and early intervention in a personalized fashion,” says Dr. Jonathon Leipsic,

THE CARDIAC SCAN IS SMALLER, EASIER TO USE AND LIGHTER THAN FULL-BODY SCANS BECAUSE IT DIAGNOSES ONLY THE HEART. chair of Providence Health Care’s Department of Radiology. It is partnering with St. Paul’s Cardiology Department in this new type of care, with funding from St. Paul’s Foundation. The clinic would open next year and will receive referrals from St. Paul’s Emergency Department, the City Centre Urgent Primary Care Clinic (UPCC) in Vancouver’s West End and from general practitioners. It will be staffed with specially trained cardiac CT technicians and nurses. The dedicated cardiac CT is currently at St. Paul’s where its scans are

performed on about 25 patients a day, freeing up time on the hospital’s other general purpose CT scans for other patients. The cardiac scan is smaller, easier to use and lighter than full-body scans because it diagnoses only the heart. It also offers: • Sharper, crisper images that can provide greater direction on the next step of care. • Similar or lower radiation doses than general-purpose scans. Patients who would be diagnosed with the cardiac scan will be sta-

ble and have symptoms that include chest pain, shortness of breath and fatigue. Patients with valve disease will also benefit. The concept of a rapid access chest pain clinic, supported by cardiac CT scanning, has proven highly effective in the United Kingdom by enabling a more specific diagnosis of coronary artery disease. As well, it will help provide earlier diagnosis to patients who might otherwise end up in the ED due to referral wait times by specialists. “If the cardiac CT scan is negative, it means the patient has an excellent prognosis with a very low cardiac-event rate for many years,” says Dr. Leipsic. The chest pain clinic will have the capacity to care for about 2,500 cardiH ac patients a year. ■

Ann Gibbon is a Senior Communications Specialist at Providence Health Care, Vancouver. www.hospitalnews.com

JULY 2019 HOSPITAL NEWS 5

IN BRIEF

New data available on

home care and mental health and addictions anadians now have more information about home and community care and mental health and addictions services in their province or territory. The Canadian Institute for Health Information (CIHI) has released three new indicators that show how Canada’s health systems are faring when it comes to how many Canadians • Are hospitalized because of harm caused by substance use • Seek frequent emergency room (ER) care for help with mental health and/or addictions • Have their hospital stay extended because the right home and community care services and supports are not ready These indicators are the first three of 12 chosen by the federal, provincial and territorial health ministries, in consultation with Canadians, to measure access to mental health and addictions services and to home and community care. This first year of results provides a baseline against which to track im-

provements over time. It will take time for new investments and renewed focus to have an impact on indicator results.

INDICATOR HIGHLIGHTS

Hospital stays for harm caused by substance use This indicator measures how many hospital stays are a direct result of substance use, including alcohol, cannabis, cocaine and other drugs. The first-year results, based on 2017–2018 data, show the following: • Every day, more than 400 Canadians were hospitalized due to harm caused by alcohol or drugs, more than the number of hospital stays for heart attacks and strokes combined. • Two out of three of these hospital stays were for men. • About 40 per cent of Canadians who had hospital stays caused by substance use also had a mental health condition such as anxiety, depression or schizophrenia. • Alcohol consumption was the top

cause of hospitalization for harm attributed to substance use across all jurisdictions, accounting for more than half of these hospital stays. After alcohol, cannabis and opioids were among the top drugs leading to hospital stays for substance use in adults. For children and youth, these hospital stays were more likely to be caused by cannabis than by alcohol or other substances. Frequent emergency room visits for help with mental health and/or addictions This indicator measures how many Canadians visited the ER four or more times in one year. In jurisdictions where ER data is available, the analysis found the following: • One in 10 Canadians who visited an ER for help with mental health and/or addictions did so at least four times in one year. • Half of these frequent ER visits were related to patients who were treated for both a mental health condition and an addiction.

• Half of frequent ER users who visited for help with mental health and/ or addictions were younger than 35. Hospital stay extended until home care services or supports ready Home care is a vital service for many Canadians who need assistance but do not require hospital care. This indicator measures the number of days patients remain in hospital while waiting for home care services or supports to be ready. According to the data, • More than 90 per cent of hospital patients had access to home care services as soon as they were ready to be discharged from hospital. But one in 12 had their stay extended because the services or supports were not ready. – This is the equivalent of three large hospitals filled each day with people who did not need hospital care. • A typical extended stay was seven days or less, but one in 10 extended stays was 39 days or more. • Patients with extended hospital H stays tend to be older women. ■

Let patients help hire your staff Continued from page 4 And the CEO for a large Metropolitan Toronto hospital said the questions posed by the patient advisor on his selection committee were some of the most meaningful and challenging that he faced. Other good reasons for having a patient or family member involved in staffing decisions. • They reflect the community and involving them shows the community the commitment the organization has to being transparent • They can provide unique perspectives on the patient experience • It helps reinforce the need for the 6 HOSPITAL NEWS JULY 2019

candidate to have patient/people skills • It demonstrates that patient partnering is part of the organization’s DNA. • It signals to the organization’s patient population that patients are valued and meaningfully involved in important decisions. • It helps to ensure the final candidate is truly someone who understands what it means to work with patients and family members as partners in delivering quality care. To make it a valuable experience for all, patients who are involved in

hiring need an outline of what the expectations are as a member of the search committee and they also need some training. To be meaningful, patients need to be involved throughout the hiring process from setting the hiring criteria and being involved in the initial screening to the final interviews. When we first wrote about this topic q a blog for Health Quality Ontario, the response was overwhelmingly positive. Both patients involved in the hiring processes in hospitals and hospital administra-

tors said patient involvement was beneficial and “demonstrated an organizational commitment to authentic engagement.” And why stop at hospitals or health care institutions and academic institutions? A good case can be made for involving patients or family members in selecting who should be admitted to medical school. While not as common a practice as involving patient advocates in institutional staffing decisions, it is happening at medical schools like the one in School of Medical Sciences, UniverH sity of Manchester in the UK. ■ www.hospitalnews.com

IN BRIEF

Oral steroids put patients with inflammatory disease at high risk of infection ral steroid use in patients with the inflammatory diseases polymyalgia rheumatica and/or giant cell arteritis significantly increased the risk of infection, and the risk increased with higher doses, found a study in CMAJ (Canadian Medical Association Journal) In a large study of almost 40 000 adult patients with polymyalgia rheumatica or giant cell arteritis in England, researchers found higher absolute risks of infection when patients were taking oral steroids than when they were not taking them. The mean

age of patients in the study was 73 years. Steroids included prednisolone, prednisone, hydrocortisone and cortisone. The risk of infection increased with higher doses and was elevated even with low daily doses of less than 5 mg of prednisolone. “In periods with prescribed medication, patients’ risk was 50 per cent higher than when it was not prescribed,” writes Dr. Mar Pujades-Rodriguez, Leeds Institute of Data Analytics, at the University of Leeds, United Kingdom, with coauthors. “Increases in risk ranged from 48 per cent

for fungal to 70 per cent for bacterial infections.” More than half of patients (22 234, 56%) had infections during 138 412 person-years of follow up, with the most common infections being lower respiratory tract infections (27%), conjunctivitis (9%) and shingles (7%). More than one-quarter (27%) of patients were admitted to hospital and seven per cent died within a week of diagnosis of infection. “Patients and clinicians should be educated about the risk of infection, need for symptom identification,

prompt treatment, timely vaccination and documentation of history of chronic infection (e.g. herpes zoster),” write the authors. They suggest that estimates of dose– response (i.e., the magnitude of risk related to steroid dosing) can be useful for policy-makers in assessing new glucocorticoid-sparing drugs for patients with these inflammatory diseases. “Incidence of infections associated with oral glucocorticoid dose in people diagnosed with polymyalgia rheumatica or giant cell arteritis: a cohort study in H England” was published June 24, 2019. ■

New report provides insights on physician services for our aging population he Royal College of Physicians and Surgeons of Canada released a comprehensive report focusing on the care physicians provide to seniors. The study, Health Care for an Aging Population: A Study of how Physicians Care for Seniors in Canada, is based on an analysis of 216 million medical services provided by almost 54,000 physicians and hones in on fundamental questions, such as how much care do physicians provide to seniors, how intensively do different specialists focus their practice on seniors and what types of medical care do seniors receive. “If we do not know how seniors are accessing care and how we are delivering it, then we do not have an accurate idea of how effective we are caring for this population with distinct needs,” says Dr. Andrew Padmos, chief executive officer at the Royal College.

THE STUDY FINDINGS REVEAL THAT

• Although seniors comprised only 16 per cent of the population, they received about one-third of all services www.hospitalnews.com

provided by physicians in 2015-16. • Together, family physicians, internists and ophthalmologists provided 85 per cent of all medical services received by seniors in 2015-16 (51%, 23% and 11% provided by each specialty group, respectively). • Some specialty groups concentrate their practices on medical care for seniors. In fact, seven specialty groups provided more than half of their medical services to seniors: geriatricians (92%), ophthalmologists (62%), cardiovascular/thoracic surgeons (57%), nephrologists (55%), oncologists (54%), cardiologists (53%) and urologists (52%). • Seniors use relatively more medical services per capita compared to the rest of the population, especially services related to diagnostic and therapeutic procedures (four times more), major surgery (five times more) and hospital care days (10 times more). • Patient gender is an important consideration in the provision of medical care to seniors. For those aged 65 and older, physicians were more likely to see women but they provid-

ed relatively more medical services to men. • The study calls for a more robust research agenda to provide provincial policymakers with data to inform health workforce planning to support this growing demographic. “Seniors will continue to be a growing part of Canada’s population and we

have good data to show how physicians make unique contributions in caring for seniors,” says Steve Slade, director, health policy and advocacy at the Royal College. “We’ve been talking about the grey tsunami for years; now it’s time to use our data to show how medical care – and all care – translates into H longer, healthier lives for seniors.” ■

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NEWS

Combining compassionate care with leading edge technology to provide the very best experience to COPD patients By Julie Dowdie or Navaratham Murugasu, Breathe Better at Home could not be a more suitable name for the program he’s been a part of at Markham Stouffville Hospital (MSH). Murugasu, who suffers from Chronic Obstructive Pulmonary Disease (COPD), is one of more than 100 patients who have participated in the pilot program run out of MSH’s Centre for Respiratory Health and COPD clinic since April 2018. “Before I joined the program, I used to visit the Emergency Department (ED) two or three times a year and once spent nearly two weeks in hospital,” says the 79-year-old Markham resident who developed COPD shortly after a stroke in 2008. “However, since I’ve been a part of it, I haven’t visited the ED once in over a year.” “COPD is a common, preventable and treatable lung disease characterized by persistent respiratory symptoms and airflow limitation. It encompasses conditions such as emphysema and chronic bronchitis,” says Dr. Allen Greenwald, Mr. Murugasu’s respirologist, who began treating him prior to starting the Breathe Better at Home program. “As a progressive and incurable disease, COPD requires close monitoring of symptoms to avoid ongoing visits to the ED and prolonged inpatient stays. The Breathe Better at Home program allows patients to play an active role in their own care journey, while also having access to an interprofessional health care team.” Patients take on this self-management role through a partnership between MSH and Cloud DX using innovative chronic disease management technology from Cloud DX. A downloadable application allows patients

COPD patient Navaratham Murugasu (left) learns about his vital signs on the Cloud DX app with Clinical Project Specialist Katrina Engel in the COPD Clinic at MSH’s Markham site. to regularly measure their vital signs, including oxygen saturation, blood pressure, heart rate, and weight – all from the comfort of their own home. Their results are monitored by their care team through a clinician portal. Early warning signs allow patients and clinicians to address issues before the patient’s health worsens. Murugasu has truly appreciated this comprehensive team-based approach, especially the care he has received from his main point of contact, Clinical Project Specialist Katrina Engel – who he affectionately calls “Madame Katrina.” “Madame Katrina, as well as everyone else at Markham Stouffville Hospital, has been very dedicated and helpful in coordinating my care,” he says. “If there’s a flare up of my COPD, Madame Katrina immediately calls

me or sends me an email and lets me know what needs to be done next. If it gets worse, she arranges a follow-up appointment with a doctor.” “Having a clinician such as myself work with patients using the Cloud DX application has so many benefits for both them and our health care system,” says Engel. “By identifying the patient’s needs and connecting them with the necessary health care resources early on, they feel supported. Monitoring and managing the patient’s care remotely and not bringing them into the hospital unless necessary also reduces costs to our health care system.” A recent analysis of the Breathe Better at Home program conducted at MSH reaffirms Engel’s comments and shows a number of positive results. Inpatient admissions and Emergency Department visits related to COPD

decreased in the six months following enrollment in the program. The program has also demonstrated some potential cost savings, as patients with COPD who are admitted may have shorter lengths of stay. As well, from a patient experience perspective, up to 83 per cent of patients enrolled in the Breathe Better at Home program said they would continue with it. With such successful results, the team is now looking to expand the program to congestive heart failure patients, those with high blood pressure, and patients with multiple chronic illnesses. Murugasu is excited others will have access to the program. “I’d tell anybody who needs it to take advantage of this incredible program and I hope others will find it as valuable as H I have.” ■

Julie Dowdie is a Senior Communications Specialist with Markham Stouffville Hospital. 8 HOSPITAL NEWS JULY 2019

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NEWS

Members of the team who contributed to the six-year long work that resulted in this discovery.

New imaging tool for diagnosing heart disease By Laura Goncalves n international team led by scientists from Lawson Health Research Institute and Cedars-Sinai Medical Center are the first to show that Magnetic Resonance Imaging (MRI) can be used to measure how the heart uses oxygen for both healthy patients and those with heart disease. Reduced blood flow to the heart muscle is the leading cause of death in the Western world. Currently, the diagnostic tests available to measure blood flow to the heart require injection of radioactive chemicals or contrast agents that change the MRI signal and detect the presence of disease. There are small but finite associated risks and it is not recommended for a variety of patients including those with poor kidney function.

STANDARD METHODS

More than 500,000 of these tests are performed each year in Canada. 10 HOSPITAL NEWS JULY 2019

A patient suspected of coronary heart disease for example may have reasonably normal blood flow at rest but as soon as they exercise they have pain or feel out of breath. They need more oxygen delivered to the heart tissue but due to vessels being compromised that doesn’t happen. The standard technique is usually done in two days with the goal of seeing if the heart can increase blood flow when more oxygen is needed. The first test studies the patient at rest to see what the blood flow is like in the heart. This is a nuclear medicine imaging test that requires radioactive material to be injected and takes about an hour or more to complete. They next day, they come for the same test but with the introduction of a stressor. That can be physical exercise but more often they are given an injection of a chemical drug which stimulates the heart and increases

blood flow. This is in addition to a second injection of the radioactive material. The heart is imaged to see the level of oxygen getting to different parts of the heart and whether there are obstructions or reduction in size of the surrounding arteries.

A NEW STRESS TEST

“We wanted a non-invasive way to image the heart and replace the stress stimulus, and drastically reduce the amount of time needed for testing,” says Dr. Frank Prato, Lawson Assistant Director for Imaging. “This new method, cardiac functional MRI (cfMRI), does not require needles or chemicals being injected into the body. It eliminates the existing risks and can be used on all patients. The team included researchers from Lawson; Cedars-Sinai Medical Center and University of California; King’s College in the United King-

dom; University Health Network and the University of Toronto; Siemens Healthineers; and, University of Edinburgh in the United Kingdom. “Our discovery shows that we can use MRI to study heart muscle activity,” explains Dr. Prato. “We’ve been successful in using a pre-clinical model and now we are preparing to show this can be used to accurately detect heart disease in patients.” To replace the stress test, this new technique uses repeat exposure to carbon dioxide to test how well the heart’s blood vessels are working to deliver oxygen to the muscle. A breathing machine changes the concentration of carbon dioxide in the blood. Levels are brought up for three minutes and then back down to normal four times. These changes should result in a change in blood flow to the heart, but does not happen when disease is present. www.hospitalnews.com

NEWS The cfMRI method reliably detects whether these changes are present and is comparable to the information gathered from the current two-day technique – in much less time and without injections. Dr. Prato notes that “we don’t want to stress the heart. We want to see whether there is capacity in the heart to increase blood flow if the heart needs to work harder.”

A BRILLIANT DISCOVERY

Other researchers have explored oxygenation-sensitive MRI but initial results contained a high level of ‘noise’ with blurry images. Project leader and partner Dr. Rohan Dharmakumar, Associate Director of the Biomedical Imaging Research Institute at Cedars-Sinai Medical Center, believed that the noise was actually variation in the heart’s processing of oxygen. He engineered a way to average this variation and through testing at Lawson the team discovered that the noise is actually a new way to study how the heart works.

WE WANTED A NON-INVASIVE WAY TO IMAGE THE HEART AND REPLACE THE STRESS STIMULUS, AND DRASTICALLY REDUCE THE AMOUNT OF TIME NEEDED FOR TESTING. “We’ve opened the door to a new era and totally novel way of doing cardiac stress testing to identify patients with ischemic heart disease” says Dr. Dharmakumar. “This approach overcomes the limitations of all the current diagnostics – there would no longer be a need for injections or physical stress testing like running on treadmills.” Through investigating this technique, they learned that the blurry images were showing normal physiological variability. People often think of heart rate as being stable, but in fact a heart that is unable to keep up with stressors indicates that disease is developing. In a healthy heart, the oxygen distribution to the tissue needs to vary.

“It’s a very exciting time. We had to bring all the technologies together to be able to image these kinds of changes in blood flow moment to moment,” says Dr. Prato. He adds that “using MRI will not only be safer than present methods, but also provide more detailed information and much earlier on in the disease process.” Following initial testing through clinical trials, he sees this being used with patients clinically within a few years.

MOVING FORWARD

In addition to studying coronary artery disease, the method could be used in other cases where heart blood flow is affected such as the effects of a

heart attack or damages to the heart during cancer treatment. Due to its minimal risk, this new tool could be safely used with the same patient multiple times to better select the right treatment and find out early on if it is working. Dr. Prato notes that “with this new window into how the heart works, we have a lot to explore when it comes to the role of oxygen in health and disease.” The next steps of the research include a proof of principle study in London, Ontario with 20 patients. Following standard tests using the conventional technique at other sites, the participants will then come in for the experimental test to show that it produces the same result. The research would then move into a multi-centre clinical trial internationally. The study “Accurate needle-free assessment of myocardial oxygenation for ischemic heart disease in canines using Magnetic Resonance Imaging” is published in Science Translational H Medicine. ■

Laura Goncalves is Lead, Communications & External Relations at Lawson Health Research Institute

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COVER

New cardiac ablation technique reduces radiation By Katherine Nazimek illions of Canadians experience irregular heart rhythms, known as arrhythmias; and, while many types of arrhythmias have no symptoms or warning signs, others may be life-threatening. In the more severe cases where lifestyle changes and medications aren’t enough to treat the irregularity, patients may undergo cardiac ablation to restore a normal heart rhythm. Cardiac ablation is a procedure in which abnormal heart tissue is burned to create scar tissue that blocks stray electrical signals. Traditionally, during the non-surgical procedure, cardiac electrophysiologists use real-time, continuous X-rays (known as fluoroscopy) to guide their instruments into and around the heart; but a new technique is helping patients and medical staff avoid prolonged exposure to radiation during the procedure. Sunnybrook Health Sciences Centre is one of few hospitals in Canada to adopt the new way of doing ablations using a three-dimensional mapping system called EnSite Precision™ cardiac mapping, which uses sensors, not X-rays, to provide highly detailed models of the heart.

HOW IT WORKS

During the ablation procedure, thin, flexible tubes with wires – called catheters – are inserted into the heart through small incisions in the skin. Diagnostic catheters record electrical information from the heart and display it on a screen in a three-dimensional model. The heart’s electrical pulses twinkle throughout the three-dimensional image, allowing the cardiologist to see any abnormalities. Abnormal tissue is then targeted using another catheter that has a specialized tip. The tip emits heat using high-frequency energy and creates a tiny scar that blocks the electrical signals causing the arrhythmia.

Cardiac electrophysiologist Dr. Ben Glover uses 3D mapping technology to avoid prolonged exposure to radiation during catheter cardiac ablation procedures.

Photo credit: Kevin Van Paassen, Sunnybrook Health Sciences Centre.

“When we move the catheters around the inside chamber of the heart, we build a map that allows us to see precisely – within a millimeter – what tissue we need to treat,” says Dr. Ben Glover, cardiac electrophysiologist at Sunnybrook’s Schulich Heart Program. “And because we are eliminating the need for fluoroscopy with this technology, we are eliminating the radiation that goes along with it.” Not only does the new approach reduce radiation exposure to the patient, it also helps protect the medical staff who may be doing three of these multihour procedures in a single day. “Conventional ablations have an immense effect on our health in the long-term. While there are strategies in place to ensure exposure is minimal, we – the physicians, the nurses, the anesthetists, the technologists – are all being exposed to X-rays to some

extent during these procedures,” says Dr. Glover. Studies show that during a 30-year career, cardiologists and other staff who work in catheterization laboratories have a cumulative radiation exposure of 50 mSv to 200 mSv, which is the equivalent of 2,500 to 10,000 chest X-rays. The impact is an increased risk of cataracts, cancer and other conditions linked to radiation. It’s not just the radiation itself that affects the health of the medical team. Using traditional fluoroscopy, the staff within the catheterization lab need to wear heavy lead aprons for protection.

These aprons can weigh up to 5 kg (11 lbs) and may be a contributor to orthopedic issues, like chronic back pain. “There is considerable evidence that many electrophysiologists or cardiologists who perform these procedures report serious back problems and other musculoskeletal concerns that end up forcing them off work,” says Dr. Glover, adding that with the new approach, lead aprons would no longer be required. Dr. Glover hopes more centres across Canada will use the fluoroscopy-free approach for the good of the H patients and the staff. ■

Katherine Nazimek is a communications advisor at Sunnybrook Health Sciences Centre. 12 HOSPITAL NEWS JULY 2019

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MEDICATION ALONE MAY NOT BE ENOUGH TO HELP ALL HEART FAILURE PATIENTS

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Breath monitoring improves patient safety during endoscopy unit procedures in pilot project By Mae Burke and Cheryl Ha pilot project in the Therapeutic Endoscopy Unit at St Michael’s Hospital in Toronto shows encouraging results for reducing respiratory complications in sedated patients by monitoring their breathing with capnography equipment during routine endoscopy procedures. The pilot, carried out within the Endoscopy Unit in partnership with Medtronic Canada, determined the incidence of respiratory adverse events in the hospital’s endoscopy unit was higher than had previously been recognized and that capnography helped reduce these events by approximately 40 per cent. “The ultimate goal for our project was to assess our current level of patient safety during procedural sedation, particularly patient safety events related to respiratory causes,” says Mae Burke, Clinical Leader Manager of the Therapeutic Endoscopy Unit. “We also wanted to see whether capnography monitoring could improve outcomes in a real-life clinical setting.” While the Canadian Society of Gastroenterology Nurses & Associates procedural sedation position statement has recommended capnography as the “gold standard” since 2015, most hospitals currently rely on pulse oximetry and visual assessment to monitor oxygen saturation in patients who undergo procedures requiring sedation in its endoscopy unit, such as colonoscopies or endoscopies. Capnography measures the amount of carbon dioxide (CO2) in breath

St. Michael’s Hospital research shows a 40 per cent decrease in adverse events with capnography. each time a patient exhales. A filter line is fitted under the patient’s nose which is connected to a monitor and also to an oxygen supply, if needed. Some medications can slow down breathing and heart rate. If that happens, an alarm will let the doctor or nurse know. Respiratory compromise is the main cause of adverse events during procedural sedation, such as apnea (temporary cessation of breathing), hypoxemia (oxygen deficiency), bradycardia (a slower-than-normal heart rate), cardiovascular shock and cardiac arrest. Research has shown that capnography can alert clinicians to respiratory depression a full minute sooner on average than pulse oximetry and that capnography is 17 times more likely to detect respiratory depression. St. Michael’s Endoscopy Unit, which conducts approximately 13,000 procedures using sedation annually, wanted to determine if capnography could help improve patient safety. The pilot project, carried out between December 2017 and June 2018, evaluated data collected on a total of 1,742 endoscopy procedures. Roughly half of these procedures – 906 – were

carried out without breath monitoring. The remainder – 836 – were completed using Medtronic’s Microstream capnography equipment, following a training period. Clinical staff used a software data collection tool based on adverse event definitions developed by the World SIVA International Task Force. The tools enabled the nursing team to enter the risk profile of the patient, type of procedure, type of clinician, sedation regime, occurrence of any adverse events and interventions. The drop in adverse events in patients whose breathing was monitored through capnography was even greater than the hospital’s endoscopy staff had expected. Prior to beginning the pilot, the hospital hypothesized that the rate of adverse events with capnography may be reduced by as much as 20 per cent. The pilot showed the decrease was nearly twice as high at 39.6 per cent. Medtronic provided intensive training to the nursing staff in the hospital’s endoscopy unit on how to use the capnography equipment at the beginning of the project. To reinforce the nursing group’s confidence around the technology, a second round of training

was provided part-way through. After a review of the outcomes data, the impact of the continuous training was clear. In the group where patients did not receive capnography, there was an average of 8.72 adverse events per 100 procedures. In the group of patients whose breathing was monitored with capnography, there was an average of 5.26 adverse events per 100 procedures. This number dropped even lower – to 3.07 adverse events per 100 procedures – after the period of retraining for the team. In another key finding, relative risk of four major adverse events all decreased with capnography, including oxygen desaturation (a drop of 32%), severe oxygen desaturation (a drop of 69%), bradycardia (a drop of 35%) and cardiovascular shock/collapse (a drop of 46%). “In keeping with St Michael’s endoscopy unit’s strong emphasis on patient safety, quality and patient outcomes in our site, our goal is to use the results of the pilot project to support the conclusion that capnography does make economic sense as well as offer superior, timely care for patients,” says H Burke. ■

Mae Burke is the Clinical Leader Manager of the Therapeutic Endoscopy Unit at St. Michael’s Hospital, Toronto and Cheryl Ha, Senior Marketing Manager, Medtronic Canada. 14 HOSPITAL NEWS JULY 2019

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World-first collaboration rewards patients and clinical teams alike By Anne Rutherford

imulation in health care is commonplace for learning or practicing skills but the value of simulation jumps to a whole new level when it brings clinical teams together to collaborate on creating standards of practice that will improve the quality of patient care. Thatâ&#x20AC;&#x2122;s exactly what happened recently when more than 35 participants across all specialties (surgery, anesthesia, perfusion and nursing) from the cardiac surgical team at Kingston Health Sciences Centre (KHSC) huddled for two days of simulations focused on the novel use of the GAMPT Bubble Counter. The simulation was the first of its kind in the world, says Chief Perfusionist Maggie Savelberg, who led the multidisciplinary effort with support from the Chief of Cardiac Surgery at KHSC and Queenâ&#x20AC;&#x2122;s University, Dr. Dimitri Petsikas, and the Chief of Cardiac Anesthesia, Dr. Tarit Saha. The Bubble Counter can calculate the number, frequency and volume of microbubbles in the bloodstream delivered to a simulated â&#x20AC;&#x153;patientâ&#x20AC;? during various scenarios where inadvertent air delivery to the patient during extracorporeal circulation is possible. The Counter provides a direct quality measure of team effectiveness in managing the critical event, and subsequently a new protocol for managing life-threatening embolisms during cardiopulmonary bypass.

L to R) Michele Kelly, KHSC Cardiac Scrub Nurse, Diana Galley, Perfusionist, and Maggie Savelberg, Team Lead Perfusionist, put the GAMPT Bubble Counter through its paces during a coronary bypass simulation. â&#x20AC;&#x153;Because gas bubbles can block vessels and cause neurological events such as stroke, monitoring and managing their delivery is critical to patient safety,â&#x20AC;? says KHSC cardiac surgeon Dr. Gianluigi Bisleri. â&#x20AC;&#x153;Fortunately, stroke-related events in cardiac surgery are rare but when they do occur they can have a devastating effect,â&#x20AC;? he explains. â&#x20AC;&#x153;That makes it critical for us to continuously optimize our practice to improve outcomes.â&#x20AC;? It can be difficult to capture data about rare events precisely because they happen infrequently, says Savelberg. â&#x20AC;&#x153;The beauty of data-driven simulation,â&#x20AC;? she says, â&#x20AC;&#x153;is that you can repeat the event over and over and actually get objective information that

focuses team members on options for improvement. â&#x20AC;&#x153;With the Bubble Counter simulation we could assess not just how quickly we responded to inadequate oxygenation in the patient but also the quality of the response. Practicing is one thing but also having a way of doing quality assurance so we can fine-tune that practice and improve the standard of care is what lifts our cardiac program above others.â&#x20AC;? That boost also comes from having a program where specialists â&#x20AC;&#x201C; cardiac surgeons, perfusionists, nurses and anesthesiologists â&#x20AC;&#x201C; converge in the simulation environment to collaborate. All levels of expertise accessed the same scenarios to discover where errors happen and how to overcome them.

â&#x20AC;&#x153;Allowing staff to feel, see and evaluate their practice is always a huge opportunity,â&#x20AC;? says Christine Wilkinson, KHSC Program Operational Director for Perioperative Services. â&#x20AC;&#x153;It lets a new protocol emerge from the clinical team itself, which means everyone is moving forward in the same direction. In this instance, KHSC has the potential to act as a benchmark for other organizations when it comes to safety in bypass surgery.â&#x20AC;? The Cardiac program now runs two simulation sessions annually to enhance its quality of service. â&#x20AC;&#x153;Innovation is not always about a new device,â&#x20AC;? says Dr. Bisleri. â&#x20AC;&#x153;It can be about making a process better. Weâ&#x20AC;&#x2122;re always striving for improvement. As a standard of practice, simulation is not that common in many health sciences centre but it plays a key role at KHSC in helping us to adopt tools and processes that make surgery safer for our patients.â&#x20AC;? For Savelberg, the big takeaway of the simulation was the strong spirit of collaboration focused on concretely improving care. â&#x20AC;&#x153;I think there was a great sense of insight and purpose about working together to improve patient care,â&#x20AC;? she says. â&#x20AC;&#x153;People felt respected, involved and capable. When you have that kind of collaboration and genuine appreciation for what each person brings to the work we do, then the magic H happens.â&#x20AC;? â&#x2013;

Anne Rutherford works in communications at Kingston Health Sciences Centre.

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JULY 2019 HOSPITAL NEWS 15

EVIDENCE MATTERS

Balancing bleeding risk and clotting risk: How long should patients be on antiplatelet drugs following percutaneous coronary intervention?

By Dr. Brit Cooper-Jones common challenge in the area of cardiovascular care is balancing bleeding risk versus clotting risk. Many people have heard of “antiplatelet drugs” (medications that reduce the risk of the blood forming clots) and may even be taking them themselves. Antiplatelet drugs play an important role in reducing the risk of heart attacks, strokes, and other clotting-related conditions. However, these same medications, by their very mechanism of reducing clot formation, also put patients at a higher risk of bleeding. As such, decisions around whom to prescribe antiplatelet drugs to – including what drug(s), and for how long – are not ones that are taken lightly. While antiplatelet drugs can be a lifesaving medication in many cases, we want to ensure that the benefits outweigh the risks before deciding how to proceed. One area of medicine where antiplatelet drugs are routinely given is following percutaneous coronary intervention, or “PCI.” PCI is frequently performed in patients following a heart attack, or for the treatment of angina (pain that results from a partial blockage of one or more coronary arteries). The procedure involves inserting a catheter into the patient’s groin or arm, and then threading the catheter through the patient’s blood vessels until it reaches the narrowed or blocked artery. A balloon is then inflated to help re-open the affected artery, and a stent is often inserted. Following PCI with stent insertion, antiplatelet drugs are important because they help to prevent subsequent heart attacks, strokes, clots at the site of the stent, and other complications. Typically, two drugs are given: aspirin, and something called a P2Y12 inhibitor. Examples of P2Y12 inhibitors include clopidogrel, prasugrel, and ticagrelor. When both aspirin and a P2Y12 inhibitor are prescribed, it is

called dual antiplatelet therapy, or “DAPT.” Of note, the question facing the health care community is not whether to prescribe DAPT following PCI with stent insertion – this has already been established as the standard of care. Rather, the key questions are: how long should DAPT be prescribed (the standard duration of six to 12 months or for an extended duration of greater than 12 months), in what subsets of patients should extended treatment be considered, what P2Y12 inhibitor (if any) is superior to the other(s), and should extended DAPT be publicly funded? To help answer these questions, and to guide decisions about the optimal prescribing of DAPT post-PCI, decision-makers and the health care community turned to CADTH – an independent agency that finds, assesses,

and summarizes the research on drugs, medical devices, tests, and procedures – to find out what the evidence says. CADTH conducted a Health Technology Assessment (HTA) that evaluated the comparative clinical effectiveness and safety, as well as the comparative cost-effectiveness, of standard-duration versus extended-duration DAPT following PCI with stent insertion. The HTA also looked at the evidence for clinically relevant subgroups, to see if certain subsets of patients may benefit more than others from extended treatment. Three different P2Y12 inhibitors were considered: clopidogrel, prasugrel, and ticagrelor. The Canadian Drug Expert Committee (CDEC) then developed recommendations based on the findings from CADTH’s report. Overall, the evidence found that extended-duration DAPT was benefi-

cial, both from a clinical effectiveness and a cost-effectiveness standpoint, for many but not all patients. The main benefits included a decreased risk of subsequent heart attacks and/ or clots at the site of the stent. However, these benefits were accompanied by an increased risk of bleeding. As a result, CDEC recommended the reimbursement of extended DAPT, but also noted that the risk-to-benefit ratio of extended DAPT varies based on the individual characteristics and risk factors of each patient. At the time of their deliberations, there was insufficient evidence for CDEC to make specific subgroup-level prescribing recommendations. The committee instead noted that the decision to extend treatment needs to be highly individualized and based on a cardiovascular specialist’s assessment of each patient. With regards to drug choice, there was insufficient evidence to determine whether clopidogrel, prasugrel, or ticagrelor was preferable for patients receiving extended DAPT. Therefore, it was recommended that all three drugs be reimbursed, and that the choice of drug be left to the discretion of the treating physician. Finally, while the majority of the patients in the research studies had drug-eluting stents (and therefore CDEC’s recommendations pertained to patients with drug-eluting stents), CDEC noted that this should not preclude the reimbursement of extended DAPT for patient with bare metal stents. To view CADTH’s full report, see: https://cadth.ca/dual-antiplatelet-therapy-following-percutaneous-coronary-intervention-clinical-and-economic-impact And if you would like to learn more about CADTH, visit cadth.ca, follow us on Twitter @CADTH_ACMTS, or speak to a Liaison Officer in your H region: cadth.ca/Liaison-Officers ■

By Dr. Brit Cooper-Jones is a Knowledge Mobilization Officer at CADTH. 16 HOSPITAL NEWS JULY 2019

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Diabetes drug reduces heart and kidney problems By Ellie Stutsman clinical trial led by researchers at the Population Health Research Institute of Hamilton Health Sciences (HHS) and McMaster University has found that the drug dulaglutide reduces heart and kidney issues in middle-aged and older people with Type 2 diabetes. The “REWIND” study followed more than 9,900 people in 24 countries over five years and found that cardiovascular events like heart attacks and strokes were reduced by 12 per cent in people taking dulaglutide compared to people taking a placebo. This effect was seen in both men and women with or without previous heart disease. During the same period, the drug reduced the development of kidney disease by 15 per cent.

The trial was led by Dr. Hertzel Gerstein, endocrinologist at HHS and professor of medicine at McMaster University. “Compared to others, people with diabetes have twice the rate of heart attacks and strokes, and up to 40 per cent of people with diabetes develop kidney disease,” says Dr. Gerstein. “The REWIND trial shows that dulaglutide can safely reduce these events while improving diabetes control lowering weight and blood pressure in middle-aged people living with Type 2 diabetes.” Nearly one in five people over the age of 60 have diabetes and most have Type 2 diabetes. Altogether, nearly ten per cent of adults are living with diabetes, including 425 million people worldwide; 100 million in the U.S.,

The trial was led by Dr. Hertzel Gerstein, endocrinologist at Hamilton Health Sciences Centre and professor of medicine at McMaster University. and three million people in Canada. Dulaglutide is taken via injection once per week. It is approved for glucose lowering and works by helping the pancreas release the right amount of insulin when blood sugar levels are high, slowing the emptying of the stomach after a meal, and reducing appetite and weight.

Dr. Gerstein notes that study participants were very similar to the sorts of people with diabetes who are seen in medical practice. Participants were followed for about five years, much longer than previous trials, and more than 46 per cent of participants were women. Less than a third of participants had H previous cardiovascular disease. ■

Ellie Stutsman is a Public Relations Specialist at Hamilton Health Sciences.

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ETHICS

Complementary medicine and chronic illness By Ruby Shanker espite strides made in research and clinical practice of Western medicine to improve the management of illness trajectory, the rising utilization of complementary medicine among persons living with chronic illnesses can be baffling to clinicians. “I have so much to offer my patient. Why would they turn to complementary therapies?” Such a query requires thoughtful reflection on the living experiences of persons with chronic illnesses. Receiving a chronic illness diagnosis can be a life-altering event. Whether relating to cardiovascular, respiratory, endocrine, or autoimmune conditions, the patient experience literature describes expressions of helplessness, frustration, and loss of control. Diabetes and chronic renal failure feature prominently in patient experience discourses where the overall management tends to be described as hijacking one’s life choices. Hemodialysis up to a few times per week means heavy-duty time commitments for individuals who then worry about disruptions to employment, financial well-being, care of dependents, and sometimes unstable housing. Clinic appointments, transit woes, chronic fatigue, and depression can interfere with the ability to engage in meaningful relationships, and may even rob from younger individuals a carefree childhood or youth. These impediments significantly impact the individual’s ability to exercise relational autonomy, or sense of self and determination based on how one situates themselves within meaningful social relations. Diet restrictions can be devastating when unable to savor foods that one attaches to comforting memories and cultural identity. The presence of highly involved family members can be a boon for support, but also a bane for those dreading loss of independence. Stigma attached to chronic illnesses or

18 HOSPITAL NEWS JULY 2019

attributions of personal responsibility for acquiring what are deemed lifestyle illnesses may force patients’ to keep their illness hidden leading to social isolation. Being reduced to merely an identity of illness is a constant nightmare. Loss appears embedded in the narratives of patients with chronic illness, almost as if one may be continually grieving. Systemically, our labyrinthine healthcare system isn’t the easiest to navigate or flexible for those trying to live a life beyond their illness. Inequitable access to nutritious yet affordable foods disadvantage those from

lower socio-economic backgrounds or geographic food deserts. Patients may experience discrimination based on their identities of race, ethnicity, gender, sexuality, and/ disability. Clinical teams may be perceived as unyielding authorities of power that dictate care, impacting patients’ willingness to trust information provided for crucial healthcare decisions. Unsatisfied with care and yearning for more control over life choices, it should not be a surprise that patients living with chronic illnesses may at some point be drawn to explore the benefits of complementary medicine.

Complementary medicine ranges broadly across diet, body techniques, and energy therapies. Most are philosophically oriented towards holistic approaches to lifestyles, and sometimes offer a centering sense of identity where there is cultural familiarity. However, patients may be enticed to unregulated complementary medicine for unsubstantiated symptom relief, promises of less restrictive diets, or speciously, for “a cure”. Concerns here are ethically justified in terms of potential harms. Ingestion of certain herbal therapies have been known to cause severe drug interactions and www.hospitalnews.com

ETHICS

sometimes fatal organ failure. When performed poorly, manual manipulation can inflict musculoskeletal injury, worsen vasculitis, and cause internal bleeding. Unbridled hope for “cures” can prevent appreciation of declines, acceptance of scam therapies, and cause moral distress to those involved in caring and supporting the patient. There is certainly need for more prospective, large-scale, and validated research on the efficacy of complementary therapies, as well as better regulation of standards to instill confidence in clinicians wishing to encourage integration. In the interim, the Internet continues to serve as a vortex of free, readily accessible and unverified information. In comparison, validated research on western medicine remains beyond the reach of patient populations behind journal pay-walls. How can we

CLINICIANS WHO INVITE NON-JUDGMENTAL DIALOGUE ON USE OF COMPLEMENTARY MEDICINE EXPRESS ATTENTIVENESS TO THEIR PATIENTS’ INTERESTS, PROVING EFFORTS TOWARDS TRUSTWORTHINESS. expect patients to unconditionally trust the healthcare system when we live in different information universes? Yet offering copious amounts of evidence based information on western medical therapies is insufficient, and may convey resistance to differing worldviews. Further, patients may be reluctant to disclose use of complementary medicine for the fear of being judged. That individuals with chronic illnesses perhaps look to complementary medicine as better avenues for compassion,

trust, and sense of hope because they are embraced as persons beyond their illness, is a somber realization of the gap between the intent and the impact of the care we offer. As philosopher Onora O’Neill reasoned, trust must be earned by first proving one is trustworthy. Clinicians who invite non-judgmental dialogue on use of complementary medicine express attentiveness to their patients’ interests, proving efforts towards trustworthiness. Exploring the patient’s notions

for hopes and quality of life can allow for sharing of care expectations. Persons living with chronic illnesses may interpret benefits and risks differently as they endure interventions with a higher degree of invasiveness and frequency than most patient populations. While clinical teams may be oriented towards long-term improvements, patients with chronic illnesses may focus on short term wins that contribute to their on-going quality of life. Involving an ethicist can be fruitful where clinical teams, patients and their families wish to recalibrate understanding, and holistically integrate approaches to strengthen trust within the therapeutic relationship. Life with a chronic illness does not have to be about loss or isolation. It can be a narrative of persisting on new and empowering journeys beH yond an identity of illness. ■

Ruby Shanker is the Bioethicist for the Toronto General Hospital (University Health Network) and Women’s College Hospital, an Adjunct Lecturer in the Dalla Lana School of Public Health, a PhD student in Health Professions Education Research at the University of Toronto Institute for Health Policy, Management & Evaluation, and a Member of the University of Toronto Joint Centre for Bioethics.

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NEWS The structured transition program Dr. Cheril Clarson (left) and Dr. Tamara Spaic (right) developed led to improved clinic attendance and satisfaction with care among young adult patients with type 1 diabetes. Nicole Pelcz (centre) was one of the patients enrolled in the study.

20 HOSPITAL NEWS JULY 2019

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Expanding transitional support for young adults with diabetes Study shows success of transition coordinator and need for continued intervention n 2012, researchers from across Ontario, led by a team at Lawson Health Research Institute, started the first multicenter randomized controlled trial to evaluate implementation of a transition coordinator for young adults with type 1 diabetes as they transferred from paediatric to adult care. “There is a huge difference between the kind of care that they receive as children compared to adults, and that is consistent across Canada and most other countries,” explains Dr. Cheril Clarson, associate scientist at Children’s Health Research Institute, a program of Lawson, and a paediatric endocrinologist at Children’s Hospital, London Health Sciences Centre. With children, patient visits involve a variety of specialists from different areas, such as the physician, nurse educator, dietitian and social worker. “The naturally build up a long-term relationship with the team, as some children might start the program when they are two or three years old as an example.” Dr. Clarson adds that the child’s caregivers are an integral part of the process and the care team also gets to know them very well. Moving into the adult program means that the patient now has more responsibility and autonomy over their own care. They have to remember to go to appointments, fill prescriptions and maintain their daily diabetes care. “During the emerging adulthood period, your attention is taken up by many other things – leaving home, starting post-secondary education, figuring out your identity and independence,” says Dr. Tamara Spaic, Lawson associate scientist and adult endocrinologist at St. Joseph’s Health Care London. “And on top of that they need to manage their diabetes ev-

AS YOUNG ADULTS STRUGGLE TO FIND THEIR FOOTING IN A NEW SYSTEM, THERE ARE SIGNIFICANT SHORT AND LONG-TERM CONSEQUENCES WHEN IT COMES TO THEIR HEALTH. ery day. They are in a completely new system with a new care team – it’s a major transition. For many, they stop coming to appointments regularly and they don’t keep up with all of their own care.” As young adults struggle to find their footing in a new system, there are significant short and long-term consequences when it comes to their health. Some will experience acute complications like high sugars leading to diabetic ketoacidosis and hospital admission or severe low blood sugars where they can lose consciousness and have a seizure. “Different studies show between 30 to 60 per cent increased risk of complications like retinopathy, myocardial infraction, stroke and kidney disease in those who do not follow their care plan,” notes Dr. Spaic. “We see a bump in this young adult period where levels spike and their diabetes isn’t being controlled – this has impacts for both the individual and the system.” The study enrolled 205 young adults with type 1 diabetes between the ages of 17 and 20. Patients were recruited from three paediatric centres and their care was transitioned to three adult centres. The multi-centre partnership included Children’s Hospital; St. Joseph’s; Children’s Hospital of Eastern Ontario; The Ottawa Hospital; and, Trillium Health Partners in Mississauga. Participants were randomly assigned to two groups, with 104 patients in

the structured transition program and 101 patients receiving standard care. Patients were seen in the paediatric care setting for six months and then transferred to adult care, where they continued with either the transition program or standard care for one year. The core component of the program was a transition coordinator, a nurse who is a certified diabetes educator. The coordinator followed the young adults throughout the transition, interacting with the paediatric health care team to establish a base of support as they moved into adult care. They attended visits, established appropriate contacts for the patient, provided support for diabetic care, problem solved and helped navigate the system. In addition to face-to-face meetings, they were available via text messages, emails and phones calls. “We had a high recruitment rate for the population and type of study, and a high number of participants followed the full program,” says Dr. Clarson. “Our results at the end of the intervention showed that the program worked very well. By providing additional support through a transitional coordinator, the results showed better outcomes all around.” Compared to the baseline, study participants attended more care visits, were more satisfied with their care, suffered much less distress associated with diabetes, had better management on a daily basis and reported less emotional burden of diabetes.

The team then took it a step further and spent another year following the participants to see if they were able to sustain the behaviour and positive outcomes. They did not find a difference between the control and intervention groups. “Unfortunately, we found no difference in the number of visits they attended, their satisfaction with care and management of their diabetes,” explains Dr. Spaic. “When they didn’t have the intervention, they essentially went back to baseline. Our hope is to see the program extended.” Dr. Clarson adds that they developed the program so that it can be integrated in different ways, and also in difference areas of health care beyond diabetes. For example, they found that the preferred method of communication with the coordinator was text. This is an easy way to provide the fundamental support of a coordinator for longer, and it is cost-effective. “Our patients really loved the intervention. By the end of the study, they felt more comfortable being able to navigate the adult health care system. They felt empowered and responded well. They wanted to continue the program.” The next step for the researchers is to evaluate support through a virtual transition coordinator. “Closing the Gap: Results of the Multicenter Canadian Randomized Controlled Trial of Structured Transition in Young Adults With Type 1 Diabetes” was published in the journal Diabetes Care by the American Diabetes Association. Learn more about the study and read about Nicole Pelcz, study participant, who found out at 13 years H old that she had type 1 diabetes. ■

Laura Goncalves is Lead, Communications & External Relations at Lawson Health Research Institute. www.hospitalnews.com

JULY 2019 HOSPITAL NEWS 21

LONG-TERM CARE NEWS

Nutrition supplements in long- term care By Dale Mayerson and Karen Thompson t times, individuals living in long-term care face health issues that result in nutritional deficiencies, which can negatively affect their health and quality of life. Nutrition supplements can help overcome nutritional deficiencies. We all need nutrients in their proper amounts for optimum health. When diet does not provide all of the nutrients necessary, providing a resident with nutrition supplements is a strategy that is often used to improve their status. The home’s Registered Dietitian completes a full nutrition assessment in the first 21 days after a resident is admitted. Early identification of risk can facilitate timely dietary interven-

tion, assisting to prevent further decline. Individuals identified at nutritional risk will have strategies put into place to manage the risk Nutrition re-assessments are completed quarterly after admission and whenever there is a change of health status. Body weight is measured monthly and is an indicator of nutritional status. Significant unplanned weight changes are assessed and strategies are developed according to individual needs in consultation with the resident and /or the Power of Attorney.

AGING AND NUTRITION RISK

Good health depends on eating a well-balanced diet, rich in nutrient dense foods. By the time residents move

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into long-term care, changes of aging and chronic illness may have affected residents’ health. Nutrition supplements may help in bridging this nutritional gap because they can compensate or offset poor dietary habits, poor nutrient absorption, and help prevent/ delay health problems associated with aging. Social interaction and physical activity can also improve appetite. As we age, both our physical and mental health are affected. During normal aging, our metabolic rate decreases, which slows down the rate at which we burn calories. The body loses muscle and gains more fat. Organ systems may decline, causing changes to digestion and kidney function, leading to constipation, diarrhea or food intolerances. Prescribed medications may alter taste, appetite and nutrient absorption. Senses of smell and taste may decline, affecting appetite. As aging continues, poor dentition, denture fit and difficulty chewing and swallowing may lead to a reduction in food intake. Arthritis and neurological conditions may make it challenging to eat food independently. Loss of mobility can result in less activity, muscle loss and constipation. In advancing years, loneliness, depression and loss of independence may affect appetite and result in weight loss. In later years, there is also an increased risk of cognitive impairment, which also may adversely affect food intake. Skin and wound problems (e.g. skin ulcers) may also develop as a resident becomes increasingly frail and elderly. Skin breakdown increases a person’s need for protein, calories and vitamins/ minerals. Depending on the severity of the skin condition or ulcer, the calorie, protein and fluid needs may increase by 150 per cent. Residents who are already struggling to meet their nutrient needs are likely unable to consume the quantity required for optimal wound healing – that is where nutritional supplements can help!

To combat the negative effects of aging while also managing the natural aging process, residents usually benefit from increasing their intake of: Protein: to sustain muscle mass. Meats, fish, legumes and dairy products offer healthy sources of proteins. Calcium: to ensure strong bones and prevent osteoporosis. Dairy products, such as milk and cheeses, are good sources of calcium. Vit D is often supplemented to improve calcium absorption. Fibre: to promote regularity and lower cholesterol. Whole grain foods, legumes (beans), vegetables and fruits are good sources of fibre. Iron: to maintain blood health and energy levels. Red meats, eggs, and spinach are good sources of iron. Vitamin A: to foster eye health. Sweet potatoes, carrots, and squash are good sources of vitamin A. Vitamin C: to boost the immune system and to promote healing. Citrus fruits, strawberries, and peppers provide substantial amounts of vitamin C.

FOOD FIRST PHILOSOPHY

There is a philosophy that using foods is better than immediately turning to supplements when residents are not eating their usual meals. This philosophy promotes the belief that nutrients are most potent when they come from food, because foods include many non-essential but beneficial nutrients, such as carotenoids, flavonoids, minerals, and antioxidants that are not in most supplements. Providing foods that give residents extra calories and protein without increasing the overall volume can be a huge benefit for residents’ overall health. It may also be more cost effective to fortify food rather than purchase oral supplements, however extra staff time may be needed to prepare fortified foods and to assist residents to eat them. An example of a fortified food is milk mixed with skim milk powder. In www.hospitalnews.com

LONG-TERM CARE NEWS

some instances, nutrient dense foods such as ice cream, milkshakes and puddings, or frequent small meals of favourite foods work just as effectively as nutritional supplements. In order to successfully improve intake with fortified foods, it is best to know a resident’s favourite foods and to know the best time of day to provide these fortified items.

TYPE OF SUPPLEMENTS

Supplements have been used for many years as a simple treatment to address poor appetite and/or unwanted weight loss. Most supplements are sweet which is well liked by many but can be a drawback for some people. Supplements come in a variety of flavours and provide a nutritionally complete product with protein, fat,

carbohydrates, vitamins and minerals. Many types and brands exist on the market. Commercial nutrition supplements routinely used include: • “standard” product usually provides 1 Calorie per millilitre

• “1.5” provides 1.5 Calories per millilitre of product • “2.0” provides two Calories per millilitre and is helpful for people who cannot manage excess volume. In long-term care, this product is often served in 30 or 60 ml servings with medications • pudding is a supplement in solid pudding form that is suitable for residents requiring thickened fluids • diabetic formula is formulated for residents with diabetes or for those requiring less calories from carbohydrate or that prefer a less sweet taste

• “high protein” supplements provide an increased proportion of calories from protein usually providing about 15g protein in an 250 ml serving • protein powders or liquids can be used for residents with increased protein needs Other specialized nutritional supplements are also available and may be prescribed for residents with more serious health conditions such a kidney failure, respiratory issues, various gastrointestinal disorders or anorexia. Continued on page 27

LONG-TERM CARE NEWS

SMART

tech solutions in long-term care By Stephanie McDougall ike most Canadians, Jacklyn has been using SMART tech solutions in her home. Her home just happens to be in long-term care where she can now, for the first time in 21 years, regain control over her world after a slip and fall left her paralyzed from the chest down. “The most exciting thing for me has been being able to turn on my TV for myself,” says Jacklyn, “I don’t have to wait for a nurse to walk by – I hate using my call bell and the reality for me is I can’t do anything without assistance.” Jacklyn lives at Northwood, a notfor-profit continuing care organization in Halifax, Nova Scotia. Northwood, the Nova Scotia Health Authority, and national and international partners, have been awarded funding through AGE-WELL, Canada’s Technology and Aging Network, to advance research on SMART assistive technology and person-centred care solutions in continuing care. Using off the shelf devices and Canadian start-up Novalte’s breakthrough Emitto technology, the research will explore how to enable older people aging with complex mobility needs to live with greater independence and dignity. Offering remote ongoing support, Novalte’s system reduces the tech burden on both the client and organization, facilitating technology adoption. From changing the channel to bed control, Emitto allows clients to take care of tasks independently and caregivers to ensure relationships and complex care needs come first. “The nurses used to have to come help me with everything,” explains Jacklyn, “Now when they come to check on me, I can tell them that I don’t need their help and that feels so good.” The research team is led by Dr. Susan Kirkland, Professor and Head of the Department of Community Health and Epidemiology, at Dal-

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Jacklyn Carter, Research Participant and Suzanne Bright, RN Clinical Leader at Northwood housie University and Central Zone NSHA. “Over the next year, our team will set the stage for future success: we will continue to build partnerships and team capacity; develop knowledge mobilization and commercialization plans; strengthen relationships with

stakeholders; develop collaborations with other AGE-WELL projects; and recruit the full research team,” says Dr. Kirkland. “The team will be ready to hit the ground running in April 2020.” The research team brings together specialist expertise in rehabilitation

engineering, data analytics and person-centred care. All project phases prioritize engagement of older adults to ensure their experiences and needs drive customization and evaluation of the technology. Continued on page 29 www.hospitalnews.com

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LONG-TERM CARE NEWS

Steph Gagne and her father, Richard Ratcliffe.

Photo: John Hryniuk

A new technology opens up a new world By Annie Atkinson ichard Ratcliffe, soon to be 91, has had his life transformed over the past three years thanks to Connections, an AGE-WELL-supported communications platform designed to prevent social isolation by keeping older adults in contact with family and friends. Life had become lonely for the war veteran and career naval officer because of profound hearing loss from “being a little too close to gunfire in

26 HOSPITAL NEWS JULY 2019

Korea. It’s a real social liability, so the tendency is to stay out of the conversation and that’s not good,” says Ratcliffe. Things changed when Ratcliffe began using Connections, an easy-tolearn platform that features pictures of the user’s contacts and simple icons to access the different types of messaging. “My father is no longer alone. Connections has bridged so many gaps, he now shares pictures, videos, audio and text messages with family and friends on a daily basis,” says Ratcliffe’s daughter

Steph Gagne. “Words cannot express my gratitude for the ease of this program achieving something I never could.” Connections was developed for use on an iPad. The program helps to re-engage those who have vision, hearing, motor skill challenges and other barriers that isolate them from the people and services they need. It requires minimal training to use – even for older adults with no computer experience. The software program was launched by the startup Famli.net

and, to date, has been used by more than 100 residents at Sunnybrook Veterans Centre and a Revera retirement residence in Toronto. “I’d be lost without it. It opened up a whole new world,” says Ratcliffe, a resident at Sunnybrook. He exchanges messages with Gagne “many, many times during the day” and has about 50 contacts including his three children, five grandchildren, other family members, friends and business associates from Winnipeg to www.hospitalnews.com

LONG-TERM CARE NEWS Cape Breton. Ratcliffe even uses the program to conduct business inhouse as president of the Sunnybrook Veteran Residents’ Council. Using Connections, Ratcliffe sang Danny Boy and delivered it to his granddaughter while she was in a pub in Ireland having a Guinness. When she trained to be a minister and was working on her first sermons, she recorded and sent them to her grandfather. For their 30th wedding anniversary, Gagne and her husband took a twoweek trip to England. “What gave me comfort in leaving was knowing that I could still correspond with my dad through Connections.” “I felt like I was there with them,” says Ratcliffe. “Steph was sending me pictures from Trafalgar Square, Greenwich, Stonehenge, Oxford, all kinds of places in England that I had been myself. It was a great reminiscence.” Ratcliffe and Gagne look forward

to seeing Connections used by older adults everywhere who could benefit from the easy-to-use communications tool. Famli.net is in discussions to expand its clientele to other veterans’ hospitals, retirement homes and seniors’ organizations in Canada, and plans to launch a multi-platform version of Connections not only in Canada, but in Singapore through several organizations that provide community care to seniors. “Connections opened up horizons for my dad. He’s now challenged and stimulated in a way that he hadn’t been for a long time,” says Gagne. “It has brightened his world.” Connections was developed by TAGlab at the University of Toronto. TAGlab and Famli.net have deep roots at AGE-WELL as they are funded through the network’s Core Research Program. AGE-WELL is Canada’s H Technology and Aging Network. ■

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

Continued from page 23

Nutrition supplements STRATEGIES TO ADDRESS APPETITE AND WEIGHT CHANGES

Typically a good starting point is to start with food first, giving a little extra at a meal, using fortified foods, or adding scheduled snacks. If this does not have the desired results, then a commercial supplement may be considered. The Registered Dietitian or Nutrition Manager discusses this with the resident and/or family and an order is written by either the Physician or the Registered Dietitian. The resident’s plan of care will include information regarding the supplement and the intended goal. Nutritional supplements are most often offered as between-meal

snacks as eating regular meals is preferred and encouraged. Additionally, when supplements are given at mealtimes, a resident will feel full after taking the nutrient dense supplement and may not be able to eat the full meal.

CAN FAMILY /FRIENDS HELP?

Encourage families and friends to visit at mealtimes and to assist loved ones in the dining room. Advising the Registered Dietitian and Care Team about the resident’s eating patterns, favourite foods or comfort foods can contribute to a more effective care plan to support optimal nutrition for H the resident. ■

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

Personalized home care services At Bayshore Home Health we understand that leaving home can be a challenge and that staying at home is the best ŽƉƟŽŶ ĨŽƌ Ă ůŽƚ ŽĨ ŽůĚĞƌ ĂĚƵůƚƐ͘ Ɛ ǇŽƵƌ neighbourhood care provider, we are ŚĞƌĞ ƚŽ ƐƵƉƉŽƌƚ ǇŽƵ ĂŶĚ ǇŽƵƌ ĨĂŵŝůǇ ƚŚƌŽƵŐŚ ĞǀĞƌǇ ƐƚĞƉ ŽĨ ƚŚĞ ĐĂƌĞ ƉƌŽĐĞƐƐ͘ FREE IN-HOME CONSULTATIONS NO LONG TERM CONTRACTS BONDED & INSURED CAREGIVERS

Support is just a phone call away. 1.877.289.3997 www.hospitalnews.com

www.bayshore.ca JULY 2019 HOSPITAL NEWS 27

FROM THE CEO’S DESK

How AI can support people’s health at home By Dr. Alex Mihailidis here’s understandably a lot of focus these days on the role that artificial intelligence (AI) can play in the health-care system. With its ability to analyze vast amounts of data, AI holds great promise as a tool that health professionals can use when making diagnoses and treatment decisions. What’s often missing in the conversation about AI is how it can support people’s health and well-being at home and in the community – keeping us out of hospital and long-term care. This has to change and soon. It’s no secret that our population is aging, placing strain on the health-care system and overburdened long-term care facilities. And most of us want to remain in our own homes as long as we can. AI can make this possible. Smarthome systems can help people stay safe, independent and healthy. Sensors, for example, have the potential to detect changes in a person’s health and provide warnings before things deteriorate. Imagine a bathroom with flooring that can monitor someone’s blood pressure and heart rate. In my own work, we have created an intelligent emergency-response system that uses AI and computer vision to detect falls in the home. It ‘learns’ a person’s habits, knows when something has gone wrong and can interact with the person or call for help, if necessary. Other AI-based systems now in development can prompt older adults with cognitive impairment to do daily activities such as taking medications and making meals. A generation ago, none of this would have been imaginable. Welcome to the future. Today, we have widely-recognized expertise in AI in Canada, but we need to focus more attention – and more people – on developing AI applications to help older adults stay

Dr. Alex Mihailidis

WHAT’S OFTEN MISSING IN THE CONVERSATION ABOUT AI IS HOW IT CAN SUPPORT PEOPLE’S HEALTH AND WELL-BEING AT HOME AND IN THE COMMUNITY – KEEPING US OUT OF HOSPITAL AND LONG-TERM CARE. longer in their homes. This area has tremendous potential but also challenges. Training AI algorithms requires high-quality data. Hospitals have electronic health records and other sources – imperfect though these may be. Home is a different story. Data sets there are small and ‘messy.’ Case in point: my team set out to develop a data set that could be used to predict dementia. We installed non-invasive motion sensors

in the homes of more than 300 people. But there were so many problems – the system would pick up multiple people moving around in the environment, for instance – that we could only use the data set from approximately 60 people. Despite these challenges, research teams at AGE-WELL, Canada’s Technology and Aging Network, are making significant strides in applying AI to home settings. We are developing

socially-assistive robots, in-home therapies and remote health-monitoring tools. There are systems to detect night-time wandering, or to show if someone is unstable when rising in the morning, indicating a decline in mobility. AGE-WELL also studies ethical, privacy and security factors associated with new technologies. But for several reasons, work in this area is in a precarious situation. First, the federal Networks of Centres of Excellence (NCE) program, which has funded AGE-WELL since 2015, is being phased out over the next few years. AGE-WELL can only apply for three further years of NCE funding – and nothing after that. Alternative funding must be found. Second, the federal government announced a $125 million Pan-Canadian Artificial Intelligence Strategy in 2017, led by the Canadian Institute for Advanced Research (CIFAR). It’s a laudable initiative but it needs to pay more attention to AI applications that can support people’s health at home and in the community. Third, Canada’s new AI institutes in Edmonton, Montreal and Toronto must, in addition to hospital-based data, place a greater emphasis on developing repositories of community-based data that researchers can use to build AI systems for the home and community. Partnering with organizations that look after people in the community can help to generate this much-needed data. By creating rich data sets, we will attract more AI researchers to this crucial area. AGE-WELL, which was established to bring together everyone in the field of technology and aging, is ready to be the leader in pushing this forward – because the future of aging depends H on it. ■

Dr. Alex Mihailidis is scientific co-director and CEO of AGE-WELL (agewell-nce.ca), a federally-funded Network of Centres of Excellence. Dr. Mihailidis is also a professor at the University of Toronto and a senior scientist at KITE Toronto Rehab-University Health Network. 28 HOSPITAL NEWS JULY 2019

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LONG-TERM CARE NEWS Continued from page 24

SMART tech solutions For example, research participants will self-report the impact of the technology on their well-being, independence, social connectedness and health supported by Age Care Technologies (ACT) of Scotland. Working to improve the lives of older people, globally, through development of tools and training in person-centred care, the ACT tool was recently recognized by the International Longevity Center–UK as a oneof-seven high-impact innovations for affordable and sustainable healthcare in the 21st century. The project will also use state of the art knowledge based tools to drive care planning pathways, empowering point of care staff where it matters most. Think Research, project partner and leading provider of evidence-based clinical decision support tools, will build standardized, innovative and

easy-to-use solutions to support this project. These digital tools will incorporate SMART tech into clinical workflows and facilitate measurement of quality improvement, enabling improved health outcomes.

year of seed funding. Projects that demonstrate sufficient progress during the Catalyst phase will be selected for three-year funding of up to $600,000, commencing April 1, 2020 as part of AGE-WELL’s Core Research Program, contingent on AGE-WELL’s renewal. This initiative, first of its kind in North America, could shift how care

THE RESEARCH TEAM BRINGS TOGETHER SPECIALIST EXPERTISE IN REHABILITATION ENGINEERING, DATA ANALYTICS AND PERSON-CENTRED CARE. The big picture is to explore the feasibility, usability, sustainability and scalability of SMART tech solutions to support increased quality of life for residents and clients in Continuing Care. The team has been allocated a Catalyst Award of $30,000 for one

is delivered for this client population. The collaborative national and international team now engaged in this research seeks to create a community that inspires a self-directed experience, restoring the “power of choice” to people, so that they can truly live more.

“The research team will be embedded in the Northwood community enabling rich daily connections with residents, staff and families,” says Margaret Szabo, Northwood’s Director of Business Development and Project Co-lead. “At Northwood, one of our core values is ‘we can always do better’ and we live this value by investing in innovation and new technologies. Northwood will act as a Living Innovation Lab helping to drive action-oriented research that directly helps older adults to live more in a community of belonging, dignity and choice.” For Jacklyn, this technology means she has a voice to make those choices for herself. “I still have a voice inside my body, and with the technology I’m able to use my voice to do things my body can’t,” explains Jacklyn, “If you can change one small thing for the better in my little world, it can have H a huge impact.” ■

Stephanie McDougall is the Communications & Marketing Specialist at Northwood.

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