Hospital News October 2019 by Hospital News

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October 2019 Edition

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A bitter pill. Doug Ford’s restructuring of health care is a prescription for disaster. Big decisions are happening behind closed doors. His funding and service cuts are already creating confusion about access to care. After just one year in oﬃce, Doug Ford has proven his only remedies are quick ﬁxes and wishful thinking. Tell your MPP, the Health Minister, and Doug Ford you won’t accept more cuts to Ontario’s health care.

Contents October 2019 Edition

IN THIS ISSUE:

Infection Control Supplement

▲ Cover story: The war against nicotine

▲ Ontario Shores celebrates 100 years

▲ Cannabis and alcohol substance abuse in youth

COLUMNS Guest editorial .................4

In brief .............................6 Evidence matters ...........21 Ethics .............................38 From the CEO’s desk .....40 Safe medication ........... 44 Long-Term Care ..............46

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▲ Biomarkers of suicidality

Election coverage

12–15

▲ Dogs helping detect C. Difficile

Making mental health a priority By George Maringapasi he fall season marks an important time for us to discuss mental health issues in Canada. Students are returning to school and many workers are back full-time after summer vacations. Additionally, we recently recognized World Suicide Prevention Day, an impactful day which raises awareness about the risks of suicide and prevention activities, and in October we mark Mental Illness Awareness Week (MIAW). Mental health is a real priority for many Canadians, with one in five Canadians experiencing a mental health problem or illness. In 2019, mental illness is still a very evident and real issue across our country. According to Statistics Canada, 4,000 Canadians die every year as a result of suicide, and many of these individuals were dealing with a mental health problem or illness. Mental health problems and illnesses are the leading causes of disability in Canada, affecting almost seven million working age adults. A key tool in helping these Canadians struggling with mental illnesses is ensuring they have access to the appropriate resources, including the ability to seek help from a licensed professional. There are many different types of trained professionals who are well edu-

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cated and can provide mental health services. While most people know of psychologists and psychiatrists – although many may struggle with the difference between the two – there is a chance they may be even less familiar with counsellors and psychotherapists. Counsellors and psychotherapists have extensive education that includes a minimum of a master’s level training, and the profession is statutorily regulated in five provinces; Nova Scotia, New Brunswick, Ontario, Quebec and Alberta (in progress). Counsellors and psychotherapists are trained to deliver culturally appropriate services, and are one of the most cost-effective mental health services available. So why then, do we make it so hard for people to seek help from this profession? Over the past few years, we have seen health plans grow to cover more and more mental health services, paving the way to bridge the gap between the services offered when comparing plans for physical and mental health. However, most health plans still fail to cover essential mental health services like psychotherapy and counselling. Including this resource in the continuum of care would help address the shortage, growing demand and increasing cost of mental health services. Continued on page 6

George Maringapasi, Canadian Counselling and Psychotherapy Association Director for Nova Scotia. If you or someone you know is looking for support, please go to www.ccpa-accp.ca where you can learn more about CCPA and search for a counsellor or psychotherapist in your region.

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ADVISORY BOARD Barb Mildon,

RN, PHD, CHE VP Professional Practice & Research & CNE, Ontario Shores Centre for Mental Health Sciences

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President Brainstorm Communications & Creations

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NEWS

Creating new mental health supports for

South Asian communities By Sean O’Malley Centre for Addiction and Mental Health (CAMH) team has been given just over a million dollars from Health Canada to develop a culturally adapted form of Cognitive Behavioural Therapy (CBT) for Canadians of South Asian origin. Canada is home to 1.6 million people of South Asian origin, the largest racialized group in the country. Previous research has shown higher rates of anxiety and mood disorders for this population compared to immigrants from other parts of the world, primarily due to cultural and socio-economic factors. People of South Asian origin also have the highest perceived barriers to mental health treatment, and are 85 per cent less likely to seek treatment for mental illness than those who identify as white. This is the first major project to develop and test culturally adapted CBT for South Asians in North America and Europe. “The evidence shows that CBT is as good as medications to treat depression and anxiety, as well as to prevent relapse,” says grant recipient CAMH psychiatrist Dr. Farooq Naeem. “But we also have a lot of data that shows that CBT does not work as well with people from non-western cultural backgrounds. When we adapt it for other cultural contexts – as we’ve done for other racialized communities – it becomes far more effective.” “CAMH’s project is a welcomed approach in improving the mental health interventions for Canadians of South Asian origin,” says the Honourable Ginette Petitpas Taylor, Minister of Health. “The investment announced today is a further step in the Government helping Canadians access mental health supports and re-

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sources that meet their specific needs and help them lead healthier lives.” Shreya Kumar, 26, who was born in India and came to Canada when she was 18, knows from personal experience the stigma that people of South Asian origin feel about seeking treatment for mental illness. Despite experiencing major depression beginning when she was 17, she did not seek treatment until almost five years later. “Among South Asians, if you’re faced with a challenge, you should be able to cope with it and if you’re not, you’re doing something wrong,” says Shreya. She is now working as a freelance graphic designer for The Roshni Project, an awareness initiative supported by the CAMH Foundation that has helped to create culturally grounded mental health supports and resources to enhance the mental health of young South Asian women. “It was such a profound experience for me to be with so many other young South Asian women who were going through what I was going through,” says Shreya. “It helped me realize how powerfully my culture is associated with my mental health.” The culturally adapted CBT initiative for Canadians of South Asian heritage will include: • The creation of guidelines informed by consultations with patients, caregivers, mental health professionals and community leaders. • Pilot Feasibility Testing of culturally-adapted CBT to be conducted in Vancouver, Ottawa and the Greater Toronto Area in order to assess its acceptability and effectiveness. • Training for 20-30 therapists on the use of the new guidelines. The goal is to produce a culturally adapted CBT manual as well as a

CAMH psychiatrist Dr. Farooq Naeem has received a grant to develop a culturally adapted form of Cognitive Behavioural Therapy for Canadians of South Asian Origin. training package for therapists working with people of South Asian origin with depression or anxiety. Longer term, the team hopes they can serve as a model for other types of culturally adapted CBT programs across Canada for other racialized groups. “CAMH has had a great experience in adapting CBT for people of African and Caribbean origin,” says principal co-investigator Dr. Kwame McKenzie,

Director of Health Equity at CAMH and CEO of the Wellesley Institute. “When culturally adapted CBT was used at Women’s Health In Women’s Hands Community Health Centre it significantly improved equity in care and decreased the number of their patients coming to the CAMH Emergency Department in crisis. We hope to have the same impact for the South H Asian population.” ■

Sean O’Malley is the Senior Media Relations Specialist at CAMH.

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IN BRIEF

mental health Continued from page 4 Wait times for mental health services are a major issue in Canada with this growing demand and shortage of care, which can potentially cause negative consequences and create further obstacles for those who are struggling with their mental health. It is critical that we strive to utilize the most appropriately trained mental health professionals either as individual practitioners or as members of multi-disciplinary teams. The role of counsellors and psychotherapists is complementary to the work of other service providers, and expanding coverage to include mental health providers such as counsellors and psychotherapists will result in quicker access to mental health care. Canadians struggling with their mental health should not be prevented from receiving the care they need due to long wait times or budgetary constrictions. Mental health problems leave citizens carrying enough of a burden, and our hope is that the system helps, not burdens them further. Several health plans will cover any chronic physical illness until it is manageable and yet, mental health and mental illness chronic conditions are not covered by many health plans. This is a problem we would like to see rectified for Canadians. Often, if mental health issues aren’t properly treated in a timely manner, quality of life begins to decline quickly as these issues affect so many aspects of an individual’s overall life. Changes to coverage in health plans, including the addition of counsellors and psychotherapists, will aim to increase the public’s access to professional, appropriately trained mental health care, reduce wait times for access to care, and improve individuals’ quality of life. Our goal is to contribute to the mental health and well-being of all Canadians. We can start by making access to mental health services a priority. The Canadian Counselling and Psychotherapy Association (CCPA) continues to advocate for more timely and accessible mental H health services across Canada. ■ 6 HOSPITAL NEWS OCTOBER 2019

Increased depression and suicidal behaviour risk for young cannabis users A

dolescent cannabis use has been linked to an increased risk of depression and suicidal behaviour in young adulthood, according to the first meta-analysis by a team of scientists at the Research Institute of the McGill University Health Centre (RI-MUHC) and McGill University, in collaboration with the University of Oxford and Rutgers University-Camden, which was published in the journal JAMA Psychiatry recently. The conclusions were reached by a team led by Dr. Gabriella Gobbi, a researcher in the Brain Repair and Integrative Neuroscience (BRaIN) Program of the RI-MUHC and a Professor of Psychiatry at McGill University’s Faculty of Medicine, following a systematic review and meta-analysis of international studies comprising 23,317 individuals. The results reveal that cannabis use in adolescence could harmfully alter mental health, even in teenagers who did not report any depressive symptoms before starting cannabis. Little attention has been paid to analyzing the impact of adolescent cannabis use on the risk of developing depressive symptoms and mood disorders on the adolescent brain, which is

still under development until the THE FINDINGS age of 25. HIGHLIGHT THE elevated The risk is particularly IMPORTANCE OF PREVENTION INITIATIVES AIMED AT EDUCATING TEENAGERS ON THE RISKS ASSOCIATED WITH CANNABIS.

in North America, where adolescents have higher rates of cannabis use compared to their peers in other developed countries. Canadian youth aged 15-25 constitute the majority of users of all ages (spanning 20-33 per cent) while over 20 per cent of adolescents in the United States report monthly use. Researchers analyzed the risk of depression, anxiety, suicidal ideation and suicide attempts based on daily-to-occasional cannabis consumption. “The study suggests the diagnosis of depression in approximately seven percent of Canadians and Americans between the ages of 18-30 is attributable to cannabis, meaning 25,000 young Canadians and 400,000 young Americans suffer from depression because of earlier cannabis consumption,” says

co-author Dr. Nancy Mayo, a Professor in the Department of Medicine and School of Physical and Occupational Therapy at McGill University and a scientist at the Centre for Outcomes Research and Evaluation of the RIMUHC. Researchers reported instead a weaker association with anxiety. “When we started this study we expected depression to be a factor attributable to cannabis consumption, but we were quite surprised about suicide behaviour rates. Indeed, a significant percentage of suicidal attempts are attributable to cannabis,” says Dr. Gobbi, who is also a psychiatrist at the MUHC. The findings highlight the importance of prevention initiatives aimed at educating teenagers on the risks associated with cannabis use while teaching them skills to resist peer pressure. “It is clear that a lot of young people consuming cannabis are at risk of developing depression and suicidal behaviour, so it is very important for authorities to be more proactive in campaigning for prevention,” states Dr. Gobbi. “We hope the findings will spur public health organizations to apply preventative strategies to reduce H the use of cannabis among youth.” ■

Growing up in poverty doubles diagnoses of psychosis-spectrum illnesses like schizophrenia eing raised in impoverished urban neighbourhoods more than doubles the average person’s chances of developing a psychosis-spectrum disorder by middle adulthood. These are the striking findings of a new study by Concordia and University of California, Davis researchers involving nearly 4,000 families monitored over 30 years.

The study suggests intervention through social policies and investment in neighbourhood improvements could prevent future debilitating illnesses and the societal and personal costs associated with them. The authors also propose identifying young people most in need of help by observing certain child behaviours. “Reducing poverty and neighbourhood disadvantage, including a variety

of social, economic and physical characteristics, may be one pathway to improved mental health across the population,” says Lisa Serbin, Concordia University Research Chair in Human Development and one of the paper’s co-authors. “Similarly, behavioural characteristics of children, such as aggression and social withdrawal, may help identify those for whom early intervention Continued on page 7 www.hospitalnews.com

IN BRIEF

Canada leading developed countries in survival for lung and colon cancer anada has among the highest survival rates for lung cancer and colon cancer compared to other developed countries, according to new data published recently in The Lancet Oncology. Data were gathered by the International Cancer Benchmarking Partnership (ICBP) and are the most recent collection of survival statistics for seven types of cancer in seven countries: Canada, Australia, Denmark, Ireland, New Zealand, Norway and the United Kingdom.

PANCREATIC CANCER CONTINUES TO HAVE AMONG THE LOWEST SURVIVAL RATES OF ALL CANCERS IN ALL PARTICIPATING COUNTRIES. 3.9 million cancer cases were collected from cancer registries in 21 jurisdictions across the participating countries since 1995, including over 762,000 Canadian cancer cases from eight* provinces. The data show that Canada is among the world leaders in survival for most of the seven cancers observed,

except for esophageal cancer and ovarian cancer. While Canada’s overall average survival generally compares well, there is often more variation among the provinces than across the countries in this study. The 2019-2029 Canadian Strategy for Cancer Control and its action plans acknowledge this variation in survival rates across Canada and strive to promote equity of access to cancer care and quality cancer care for all Canadians. The Canadian Partnership Against Cancer (the Partnership) participates in the international study through chairing the program board and funding the collection and analysis of all contributing* provinces’ data from their cancer registries for the Canadian data included in the ICBP paper. Other findings include: • Overall, survival rates for the seven types of cancer studied are generally higher in Canada, Australia and Norway. • For all countries, survival for all types of observed cancer has increased across the 20-year reporting period. • Five-year survival from colon cancer has continued to rise considerably in all participating countries. • Pancreatic cancer continues to have among the lowest survival rates of all cancers in all participating H countries. ■

Expanded service provides mental health care to all hospital in-patients ental health is a crucial aspect of overall health. An expanded Consultation Liaison Service at Thunder Bay Regional Health Sciences Centre provides patients with increased access to specialized and appropriate mental health care. The Consultation Liaison Service team refers patients to psychiatric or behavioural management, liaison with the referring treatment team, and provides ongoing monitoring of mental status. The team also facilitates transfer of patients to other mental health care services if deemed necessary. After proving successful during the pilot project phase, the service is now available to patients in all areas of the Hospital. “We made a commitment to enhance the delivery of mental health care to patients outside of mental health services,” said Darcy Price, Acting Director of Adult and Forensic Mental Health. “This service helps us be

more sensitive to patient needs by providing timely, efficient and robust mental health care for all patients, regardless of where they are located in our Hospital.” The service also helps address the emerging substance abuse crisis that is happening across Northwestern Ontario. “We experience higher rates of substance abuse in our region, and people impacted can be patients of our Hospital,” said Price. “We are sensitive to all patient needs, and are strengthening the way we treat the whole human being – mind, body and soul.” The Consultation Liaison teams consist of a psychiatrist and a mental health nurse. They connect patients, when necessary, to the appropriate community partners and agencies that can assist them on their continued path to healing. This includes connecting substance abuse patients to proper withdrawal management services and addiction H counseling. ■

Continued from page 6 could be effective. This could act as a preventive measure in reducing major adult psychiatric disorders.” Heredity, such as having a parent with a similar illness, is a major factor in predicting schizophrenia. But this study provides clear evidence that environmental factors experienced in childhood also affect future mental health. The findings apply equally to bipolar disorder and other disorders involving psychoses – that is, breaks with reality involving delusional beliefs and hallucinations. www.hospitalnews.com

The study, “Predicting psychosis-spectrum diagnoses in adulthood from social behaviors and neighborhood contexts in childhood,” was published April 24 in the journal Development and Psychopathology. Serbin conducted this study with co-authors Paul Hastings of UC Davis and Dale Stack, William Bukowski, Daniel Dickson and Alex Schwartzman of Concordia, plus Jonathan Helm of San Diego State University and Jane Ledingham of the University H of Ottawa. ■

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OCTOBER 2019 HOSPITAL NEWS 7

NEWS

Data drives two SickKids mental health care innovations in hospital and the community By Jane Kitchen o assess the mental health needs of children and youth, The Hospital for Sick Children (SickKids) in Toronto is introducing a more integrated and evidence-informed clinical model at both its hospital and community sites. “We are aligning our data collection processes across the hospital and community sites,” says Christina Bartha, Executive Director, Brain and Mental Health program, SickKids, and SickKids Centre for Community Mental Health (SickKids CCMH). “We are starting to link our services to create a more seamless continuum from hospital to community, in order to achieve greater impact and quality between the two. For our Mental Health Consultation Liaison Service at SickKids and our redesign of our intensive services at SickKids CCMH, we used data to assess the effectiveness of the mental health care we provide, shaping the care we are offering.”

SICKKIDS: CONNECTING MENTAL HEALTH AND MEDICAL CARE NEEDS

Since 2014, SickKids has offered a Mental Health Consultation Liaison (CL) Service for patients. The service provides psychiatric assessment, evaluation, and treatment planning for medical and surgical patients who also have a concurrent mental health concern. The need for this integrated and collaborative approach was amplified by findings from the Medical Psychiatry Alliance project (2015-2020) which evaluated the effectiveness of this model in a paediatric setting. “We see many different connections between physical and mental health among patients on our medical and surgical units,” says Dr. Suneeta Monga, Associate Chief of Psychiatry, SickKids. “Children with pre-existing mental health conditions or whose mental health conditions are caused or exacerbated by their physical illness; or those

Christina Bartha (left) and Dr. Suneeta Monga are constantly assessing their programs to make sure children and youth are getting the mental health care they need.

WE ARE DOING A BETTER JOB OF FLAGGING MENTAL HEALTH CONCERNS AND RESPONDING TO THE NEEDS OF PATIENTS AND FAMILIES IN AN AREA THAT WAS PREVIOUSLY UNDER-RECOGNIZED. who develop mental health conditions from dealing with their physical illness, such as a chronically ill child who develops depression once they realize how different their life is from their peers.” The Mental Health CL Service improved staff awareness of these issues leading to better identification of patients who needed to be seen by this service. As a result, referrals more than doubled in a three-year period, from just over 200 in 2015/16 to 450 in 2018/19. The team complement now includes paediatric mental health nurse practitioners, a behaviour analyst and psychiatrists. “We are doing a better job of flagging mental health concerns and responding to the needs of patients and families in an area that was previously under-recognized,” says Monga.

SICKKIDS CCMH: RE-DESIGNING SERVICES TO RESPOND TO CHANGING CLIENT NEEDS

In 2017, the goals of the SickKids integration with the former Hincks-Dellcrest Centre was to improve access to mental health care for children and youth, particularly those with complex mental health needs. In the last two years, the new SickKids CCMH has focused on improving its clinical processes to provide more efficient access to outpatient services (OPS). Wait times to OPS have been reduced by 40 per cent, achieved through process improvement and the introduction of new service lines offering more options to families. Even with these changes,

however, there remained a gap in capacity for intensive day-based services. “We learned from an analysis of our residential services data that we were offering a rural treatment plan no longer aligned with what families and youth wanted,” says Bartha. “Rather than having a child live away from home, families are asking for day-based intensive services that are community-integrated and offer support for transition to school and other services at the end of treatment.” This finding has led to an overhaul of the intensive services model provided at SickKids CCMH, specifically the residential services stream. Over the past year, SickKids CCMH decommissioned their rural residential program known as “the Farm” and is now investing these resources into expanded day-based services at their two city sites; city-based residential care is still available when needed. At full implementation, these changes will increase service capacity by as much as 40 per cent.

WORKING TOGETHER TO INCREASE ACCESS TO CARE OPTIONS

With the growing numbers of children and youth with mental health concerns presenting at SickKids (a 66 per cent increase in mental health presentations to the Emergency Department alone between 2016 and 2018) and the relatively recent relationship with SickKids CCMH, there are many opportunities for care to be bridged between the two organizations. Historically, community-based mental health agencies have been challenged to manage clients with concurrent complex physical and mental health diagnoses. Through this innovative integration, the hospital and community sites are working toward integrated service lines that will allow these children to receive mental health care in the community, with the confidence that specialized medical care is availH able if and when they need it. ■

Jane Kitchen is a Communications Advisor at The Hospital for Sick Children. 8 HOSPITAL NEWS OCTOBER 2019

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NEWS

Screening for mental health in emergency department By Jasmine Sikand

rriving at a hospital Emergency Department (ED), patients may expect to be asked their medical condition and history as a way to give treating clinicians an accurate diagnosis. Until recently, none of those initial screening questions asked in the ED at UHN included an assessment of a patient’s mental health. But a pair of advanced practice nurse educators (APNE) have helped change that.

IN THE ED, WE ARE IN A PRIME POSITION TO NOT ONLY IDENTIFY, BUT CONNECT THESE PATIENTS WITH THE MENTAL HEALTH SERVICES. Record forms in the ED at Toronto General (TG) and Toronto Western (TW) hospitals, as well as the Urgent Care Clinic at Princess Margaret Cancer Centre (PM), now include questions that screen for mental health, including suicide. “As nurses, our responsibility is to do a comprehensive assessment of our patient,” says Brittany Jenkins, APNE at TW ED, who drove the changes along with Stephen Casey, APNE at TG ED. “If we can identify a problem early on, we can escalate to the physician or get the proper supports in place.” Toronto Rehab’s (TR) Bickle Centre also recently began using a screening tool, which is specific to suicide risks, in two of their inpatient units. Used once every 24 hours, the results are entered into a nursing documentation form. An escalation algorithm developed in collaboration with Bickle physicians

Advance practice nurse educators Brittany Jenkins and Stephen Casey drove the changes to add mental health assessment questions in the initial screening of patients in the emergency department. accompanies the screening tool, and assists nurses with decision-making about interventions related to highrisk patients. UHN is unique in having PESU (Psychiatric Emergency Services Unit) within the ED at TW, which many other hospitals don’t have. PESU takes over the care of any patient in the ED with mental health issues. However, all patients still come through the main EDs, and their primary assessments are typically completed there. “We often have patients who don’t come in for a mental health complaint, but issues with their mental health may still be affecting their everyday life, or be a factor in the condition they did come to the ER for,” Stephen says. “In the ED, we are in a prime position to not only identify, but connect these patients with the mental health

services and the care they require to avoid possible harm.” The new nursing record forms were implemented in June, with the help of a project team comprised of Kristen Cunningham, Senior Planner of Strategy and Transformation at UHN; Kelsey Hannon, Product Designer at Healthcare Human Factors; Maggie Dilling, APNE at PM Urgent Care Clinic; and Brittany and Stephen. Dr. Justin Delwo, Medical Lead of Mental Health Emergency Services at TW, supports the initiative and hopes to see more inclusion of mental health in the future. “It is so important to be inclusive of mental health in all areas to provide seamless care for our patients and ensure we really are providing the care our patients need,” says Dr. Delwo.

At Bickle, planning for the tool began in April and education started on a pilot unit in August. It is currently used by nurses, but it’s hoped that in the coming months Allied Health Professionals will be trained and it will be expanded to all other units at the site. Casey at TG says nursing staff are generally excited about the new form, but there is some discomfort in asking the questions to all patients, especially if a patient is coming in for an issue seemingly unrelated to mental health. Some of this discomfort stems from nursing staff being unfamiliar with mental health patients, as not all have had mental health training in nursing school. “There is still such a stigma around it. We need to be able to feel comfortable to ask these questions so people can talk about it, because if they’re not bringing it up and we’re not bringing it up, how can we fully help these patients and give them the support they need?” Brittany says. What helps to make nurses more comfortable is including guiding questions on the form? Brittany says staff are advised to ask at least the first two questions to patients – whether they are having any present thoughts of self-harm or any present thoughts of harm to others – and then depending on their answers, proceed accordingly. “It’s really about reminding staff that those questions should be asked in the exact same manner you would ask patients any other question, and that we are not just asking these questions to patients who come in with depression or situational crisis,” Brittany says. In addition to being able to better help the patient while in hospital, Stephen says the mental health and suicide screening gives staff the opportunity to educate patients about community resources they may never have known of before in the event they are experiencH ing some mental health issues. ■

Jasmine Sikand is a Communications Coordinator at the University Health Network’s Centre for Mental Health. 10 HOSPITAL NEWS OCTOBER 2019

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Navigating your finances as a physician When Dr. Kevin Gregg graduated from anesthesia residency at University of Calgary he began his career, as most doctors do, with substantial debt. “In my case, I left with $230,000 debt from medical training,” he said. Dr. Gregg, an anesthesiologist in Edmonton, Alberta, completed his residency in 2016, started up his practice and started a family. Needless to say, managing his finances became even more complex. Dr. Gregg, then a medical trainee , had been managing his finances with MD Financial - the service previously offered through the Canadian Medical Association that was sold for 2.6 billion dollars last year. But like many physicians, he felt surprised by their sale and lack of consultation and transparency behind the deal and wanted a change. Dr. Kevin Gregg

“After that, I explored relationships with other financial institutions. Advisors came and went and they didn’t all have the same level of expertise and experience with physicians. I was looking for someone with more specific knowledge and someone to grow with,” he said. At one bank, the branch manager was his main point of contact, which started off well. But there was staff turnover and Dr. Gregg ended up dealing with three different people over a three-year period. “It was frustrating. I needed somebody who really understood the nuances of practicing medicine,” he said. Often, he had to meet with separate advisors for different tasks. The ideal situation would be to have one advisor wellversed in the myriad of financial tasks physicians deal with.

card, and having resources to buy equipment. Then there are investments, insurance and planning for retirement. It is a relatively unique situation and it helps to have a financial institution that understands the needs of both sides and takes an integrated approach to manage, build and protect your wealth. Dr. Gregg has worked closely with Simon Belz - CIBC’s Business Development Manager in the Healthcare segment and has been very happy with the quality advice and service provided by CIBC. “I feel that my advisor really understands physicians. It’s easy to move money around my various accounts, and I’m not being nickel-and-dimed with annoying fees. The service is seamless and our advisor is exceptional,” Dr. Gregg said. He was also impressed by how easy it was to set up a line of credit, that there was minimal hassle getting a corporate card, and he can manage various tasks himself online. He works with only one advisor for everything who can be reached by email, phone and SMS, and often will meet at unusual hours. However, additional experts from other parts of the bank can be easily pulled in if needed.

We recognize that physicians work in unique environments

Then, through an online group that focused on physician finances, he learned about the CIBC Full-Service Physician Package and was one of the first people to join the program. Launched in April of this year, the service offers a comprehensive suite of solutions designed to address the diverse needs of a physician’s overall portfolio. CIBC advisors undergo additional training so they understand the corporate and personal financial structures physicians work under. Like other physicians, Dr. Gregg has both his medical practice business and personal life to manage. On the personal side, there’s the debt from medical school, costs associated with starting a family such as buying a house, and maintaining savings for emergencies and vacations. The business side includes establishing capital, getting a corporate credit

Built around what physicians want “CIBC’s Full Service Physician Package” offers a comprehensive suite of products and services to help physicians reach their business and personal financial goals, says Belz. “Consulting with doctors ensures the program is a good fit.” He explained that CIBC did intensive research which included interviews both with physicians and financial advisor. Our research provided rich insights into the day-to-day activities of doctors – the corporate structures they used, what their schedules were like, how their offices worked, whether they worked at multiple sites, financial needs in the office environment, how they needed money to flow, and how they got paid. “We recognize that physicians work in unique environments,” Belz said.

Advisors know about the various payment schemes for physicians, and the fact the legislative environment physicians operate under can change affecting taxation and renumeration. “CIBC Advisors work with physicians at all stages of their career be they recent grads, doctors who are growing their practice, or those who are transitioning or retiring,” Belz said. For physicians growing their practice, successfully managing their finances means reducing their tax burden, having a financial plan in place for retirement and having consistently well-performing investments. The goal is to help doctors maintain their lifestyle as they plan for the retirement! Having such a comprehensive program and advice that makes it radically simple to manage your finances is a big a win because, as Dr. Gregg pointed out, “We get very little training in medical school about the business side of running a medical practice.”

– By P Wysong Sponsored by CIBC

ELECTION

Leader of the New Democratic Party Jagmeet Singh ince the 1950s, New Democrats have stood up for the health care that Canadians need, in partnership with doctors, nurses, and other health care workers. As the leader of the New Democratic Party, I have met with Canadians across the country who have shared their heartbreaking stories of being unable to pay for prescription drugs, or feeling helpless because they could not afford to treat their depression. Canada’s health care system is in crisis because back-to-back Liberal and Conservative governments have failed to make health care a priority. We’re seeing the consequences of their inaction with long wait times, overcrowded emergency departments, patients on gurneys waiting in hospital hallways, and high levels of burnout amongst health professionals.

12 HOSPITAL NEWS OCTOBER 2019

As our aging population grows, our health care pressures will increase. Canadians deserve more than the existing patchwork of inadequate health interventions and programs. They deserve a government that has the courage to prioritize their health care needs rather than make empty gestures while cutting health care funding. New Democrats have a bold vision to expand our health care system by providing coverage from head-to-toe. We will fix the gaps in our health care system, starting with the launch of a national pharmacare program in 2020. Our pharmacare plan means fewer unnecessary hospital visits because patients will get the medications they need, at no cost. New Democrats also believe that we need more investments in preventative care. For example, oral health should be part of essential health care services. Too many Canadians are ending up at the hospital seeking emergency care for problems with their teeth that could have been prevented if they could afford the dental care they need. That is why New Democrats will ensure that the Canada Health Act includes dental care. From investing in mental

health to eye check-ups to long-term care, New Democrats are making health our top priority. And we plan to achieve these goals together with doctors, nurses, and health administrators who work hard to keep our hospitals and care centres running as smooth as possible. New Democrats believe that we must invest in the people that take care of us. Ongoing staffing shortages make for poor quality care and leave health care workers at risk of experiencing workplace violence. It’s time to work with the provinces and territories to take a new approach to addressing the complex health care needs of our aging population. It’s time for a government on the side of aging Canadians, their

families, and frontline health care workers. We will work with provinces and territories to address our country’s health labour challenges, and create a plan to recruit and retain health care professionals. We are committed to helping Canadians live healthier lives and building healthier communities. We can best achieve this by expanding our publicly funded health care system so that it reflects the needs of Canadians today. I believe that Canadians should have a government that’s in it for you. Warmest regards, Jagmeet Singh Leader, Canada’s New Democrats

www.hospitalnews.com

ELECTION

Leader of the Conservative Party Andrew Scheer y mother was my hero. When she graduated high school, she became one of the original nurses at the Children’s Hospital of Eastern Ontario in Ottawa. She worked hard, and even put the savings from her first job toward a renovation at her parents’ house. She taught me about the tremendous role health care providers play in the lives of patients and their families, and their ability to touch so many

through compassion and hard work. From her, I learned about the number of procedures, services, and treatments they perform, and the love, support, and care they provide for the people who come through the hospital doors each and every day. I know that my mother’s determination and good will – her story – is like so many Canadians today. As we grow older, we watch our children become parents, and in turn, we become the caregivers for our mothers and fathers. Continued on page 15

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OCTOBER 2019 HOSPITAL NEWS 13

ELECTION

Leader of the Liberal Party Justin Trudeau anada’s health care system is a source of pride, but we know we need to do more to strengthen it. No one should have to give up food and heat to be able to pay for health care, whether it’s insulin, inhalers, or mental health support. Liberals believe that every Canadian – no matter where you live, who you are or what you do – should receive the care they need to stay healthy. That is why we took meaningful steps to improve our health care system over the past four years. We successfully negotiated a new Health Accord with the provinces and territories to help reduce wait times and improve patient care – which included $11 billion in new federal investments in mental health and home care over the next decade. We brought in the most significant changes to drug pricing in nearly 30 years. We are working to establish the Canada Drug Agency to make drug purchasing more effective and efficient, and implement a national formulary with partners to set prices. We are also bringing down the high cost of lifesaving drugs for Canadians through our new Rare Disease Drug Strategy. Combined, these measures will save Canadians approximately $13 billion over the next decade. To lay the groundwork for national pharmacare, we set up the Advisory Council on the Implementation of National Pharmacare in 2018, led by Dr. Eric Hoskins.

14 HOSPITAL NEWS OCTOBER 2019

We know that there is more work to do. A re-elected Liberal government will close the gaps in the health care system, and make sure people can get the care they need – when they need it most. To do this, we will make a down payment of $6 billion to further invest in health care over the next four years, and to build on the work we have done towards universal, national pharmacare for all Canadians. Moving forward, we will begin negotiations with the provinces and territories to establish clear national standards for access to mental health services. In the last four years, we’ve made investments to improve access to treatment and address the stigma of mental illness. We will continue this important work by strengthening the Canada Health Act, so that the

full range of mental health services are available to every Canadian in every province and in every territory. We will also work with the provinces and territories to ensure all Canadians have access to a family doctor or primary care team on a regular basis. We know that routine checkups can help prevent illness and mean less time spent in the ER, which in turn reduces wait times. Finally, we will work with the provinces and territories to implement universal, national pharmacare so that all Canadians have the drug coverage they need at an affordable price. We know that the cost of drugs is a huge financial burden for many Canadians living with a chronic illness, a rare disease, or a complex condition – national pharmacare will lighten that load.

Canadians deserve a government who will support them, and that means supporting our public health system. Health care professionals know first-hand how cuts to public health programs and services harm the people who need it most. Unlike Conservative politicians like Doug Ford and Andrew Scheer – who think that you can cut your way to prosperity – we believe in investing in Canadians so that nobody has to choose between staying healthy and putting food on the table. Our Liberal team will continue to move Canada forward, as we seek to improve quality of life for Canadians and build on the progress we have already made. Leader of the Liberal Party Justin Trudeau

www.hospitalnews.com

ELECTION

Conservative Party Continued from page 13 We begin to interact with the healthcare system in new and different ways. As a result, our perspective on health care changes. Before my mother passed, she received care from Canada’s health care system that our family wouldn’t have otherwise been able to afford. It is critical for Canadians to have confidence that these programs will be there for them when they need them. That is why I recently wrote to all of the premiers across Canada to tell them about this commitment, and I am now sharing it will all Canadians. I have signed a Health and Social Guarantee so that Canadians will be able to count on stable and predictable funding from a new Conservative government. Under a Conservative government, both the Canadian Health Transfer and the Canada Social Transfer will continue to increase by at least three

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per cent every year. We will preserve Canada’s health care system over the long-term so it is there when Canadians need it. But we won’t stop there. According to a recent report by the Conference Board of Canada, Canada’s stock of MRI and CT machines is aging, supply is not keeping up with demand, and wait times for lifesaving diagnostic tests exceed the wait-time recommendation from the Canadian Association of Radiologists. A Conservative government will cut wait times for these diagnostic tests by establishing a fund to help provinces purchase new MRI and CT equipment and replace aging equipment. This will bring Canada’s medical imaging equipment in line with international standards and help Canadians get the care they need quicker. In addition to improving wait times, this investment

will also give provincial governments some additional spending flexibility, as the federal government would pick up the bill for replacing out-of-date imaging equipment that the provinces would likely have to replace. As the election approaches, I expect my opponents to distort my position on health care funding. In fact, they already have. What I’m focused on is highlighting my positive Conservative plan for Canadians across the country. That is why I want you to have my word – in writing – that I will maintain and increase funding for Canada’s health care system, ensuring Canadians have timely access to quality health services. This guarantee is my formal commitment to you. The Hon. Andrew Scheer Leader, Conservative Party

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NEWS

Cannabis and alcohol

responsible for majority of hospitalizations for substance use among youth ast year, over 23,500 youth (age 10 to 24) were hospitalized for harm caused by substance use – the equivalent of 65 hospitalizations each day. A new report from the Canadian Institute for Health Information (CIHI) shows that cannabis and alcohol were the most common substances associated with hospital stays among this age group in 2017–2018. Hospitalizations for harm caused by substance use accounted for one in 20 of all hospital stays in Canada among youth age 10 to 24. Cannabis was documented in nearly 40 per cent of these hospitalizations, while alcohol was associated with about 26 per cent. Approximately one in every six youth (17 per cent) hospitalized for substance use harms was hospitalized more than once for substance use within the same year. “Cannabis and alcohol are the most commonly used substances among Canadian youth. Every day, 65 youth are hospitalized for substance use and this is only the tip of the iceberg – for every one hospital stay, there were five emergency department visits. We’re also seeing high rates of mental health conditions with harms related to substance use. “Mental health conditions typically appear during adolescence and our report highlights the need for comprehensive, integrated and coordinated mental health and addictions services for youth. We hope this data can inform prevention and treatment efforts

16 HOSPITAL NEWS OCTOBER 2019

across the country,” says Jean Harvey, Director, Canadian Population Health Initiative, CIHI . Substance use harms requiring inpatient hospital care include overdoses, withdrawal symptoms, injuries caused by intoxication, chronic conditions and substance-induced psychoses that require mental health treatment. These harms place a burden on individuals and their families, health care systems, social services and public safety systems.

WHO IS HOSPITALIZED?

Among those age 12 to 16, hospitalization rates were higher for females than for males. However, rates were higher for males in the 19+ age group. Differences in hospitalization rates may be related to the patterns

and types of substance use, differences in physiology, and coexisting mental health conditions. For both sexes, hospitalization rates for substance use increased with age.

SUBSTANCE USE AND MENTAL HEALTH

Nearly 70 per cent of hospital stays for harm caused by substance use among youth involved care for a concurrent mental health condition. Among youth hospitalized for harms related to cannabis, 81 per cent received care for a concurrent mental health condition. Younger people were twice as likely to have a documented mental health diagnosis, compared with people age 25 and older. Mental health conditions vary and include mood disorders, schizophrenia and anxiety disorders, among other disorders.

“We know that the health and well-being of children and youth living in Canada continues to decline. At the same time, hospital visits for youth are being driven by mental health disorders and substance use. Evidence tells us that early intervention is important for the prevention and treatment of substance misuse and associated mental health disorders. Operational leaders across Children’s Healthcare Canada’s member organizations are ready to implement interventions to support and improve services for youth. This report highlights the urgent need for a pan-Canadian child and youth mental health and substance use strategy,” says Emily Gruenwoldt, President and CEO, Children’s Healthcare Canada. ■ H

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OCTOBER 2019 HOSPITAL NEWS 17

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Take a multi-surfaced approach to disinfection. Pathogens thrive on multiple surfaces, your disinfecting wipes should too.

In healthcare facilities, nearly any surface in the environment is susceptible to contamination with healthcare-associated infections (HAIs). Despite proactive infection control measures, many of these pathogens can still survive on surfaces long enough to be transmitted to patients and healthcare workers1.

Damage to dollars. The challenge we often face within the healthcare community is the spread of pathogens through various means â&#x20AC;&#x201C; from mattresses and bed rails to furniture to laminate surfaces and medical equipment. Proper cleaning and disinfection, with the appropriate disinfectants, are a vital component of infection prevention. However, disinfectants that are incompatible with medical materials can result in enormous hidden costs due to surface damage.2

Types of surface damage commonly seen in healthcare: Plastic fatigue â&#x20AC;&#x201C; Cracks/crazing usually caused by plasticizing ingredients in formula (usually solvents).

What to look for in a disinfectant.3 Efficacy â&#x20AC;&#x201C; A wide antimicrobial spectrum, including kill claims for the pathogens that commonly cause HAIs and outbreaks. Compatibility â&#x20AC;&#x201C; Products with broad surface compatibility.

Discolouration â&#x20AC;&#x201C; Can occur when a protective coating is removed and the surface is exposed to heat or sunlight.

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Residue â&#x20AC;&#x201C; Streaky or salty residues are unsightly but usually can be removed by wiping with a damp cloth. Which is double the work.

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References: 1. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis 2006;6:130. 2. Surface Compatibility Resource Guide. Clorox Professional. Clorox Healthcare. 3. Augustin-Glenn D. Challenged by surface compatibility? Donâ&#x20AC;&#x2122;t compromise: Disinfectant innovations eliminate the need for tradeoffs. Clorox Professional. Clorox Healthcare. 4. The Clorox Company. Clorox Professional.

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FROM

INFECTION CONTROL 2019

Solving common personal protective equipment challenges through simple innovation By Lindsay Samoila, Raymond Elwood and Justin Quinn n the words of Charles F. Kettering, “If you have always done it that way, it is probably wrong”. This is exactly what the infection prevention and control (IPAC) department at Hôtel-Dieu Grace Healthcare (HDGH) found was occurring with their current Personal Protective Equipment (PPE) practices. Regular quality checks identified that the current system of storing PPE on a series of carts throughout HDGH did not facilitate best practices for donning or hand hygiene. Growing linen costs and lingering low hand hygiene compliance rates were also driving the need for a better PPE storage solution.

To find a better way, an inter-professional team was created including infection prevention and control, environmental services, materials management, frontline staff, ergonomics, clinical practice and plant operations. The team conducted a comprehensive audit of the current state, focusing on identifying adherence to best practices for hand hygiene and donning of PPE throughout the organization. The audit revealed extreme hoarding of linen, expired PPE and the regular storage of other general hospital supplies on the carts. The manual replenishment of PPE on the carts without a defined process of ownership,

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 area available to members.

INFECTION PREVENTION AND CONTROL CANADA (IPAC CANADA) 20 HOSPITAL NEWS OCTOBER 2019

Raymond Elwood and Lindsay Samolia looking over glove mountain. cleaning and maintenance was found to be contributing to the hoarding and storage problems. Further, the audit illustrated that health care workers were unclear about the purpose of the PPE storage carts, and that the current storage system was contributing to missed hand hygiene opportunities and the growing linen costs. With the audit results in hand, and with an understanding of best practices for PPE location and use, the inter-professional team was able to generate a list of criteria for ideal PPE storage at point-of-care. This, coupled with extensive consultation with front line staff across the organization and through discussions with several vendors and suppliers, a new system for PPE storage at HDGH was designed. The team found it relatively straightforward to find existing solutions with vendors for mask and glove storage and placement. Gloves were moved to in room point-of-care wall-storage holders, which were stocked with all sizes. These were located next to wall, hand sanitizer dispensers to enable staff to perform hand hygiene and change gloves at point-of-care. Based on a risk assessment for our campus, only one type of facial protection mask with an attached faceshield was made available to staff. At HDGH, level two, impermeable, launderable gowns are used. An existing solution for gown storage at HDGH was not as easy to identify. This required the team to collaboratively develop a new innovative solution to meet our specific needs. After research and analysis by the team, a custom-made PPE

gown storage solution was created. This innovation included the storage of all gowns in laundered bags hung outside of each room. The gowns are delivered to HDGH in pre filled 20 gown bags, the volume of which was calculated based on parameters related to the weight and height of the wall hooks and the number of gowns required in a 12 hour time period. The team used a Plan-Do-StudyAct Quality Improvement Cycle to support the standardized adoption of the appropriate donning sequence of PPE and four moments of hand hygiene using the new system. The impact of the new PPE storage system indicated some significant changes, including: • A 27 per cent reduction in protective gown consumption, representing a cost savings of $24,706.91 in a one year period • An eight per cent reduction in glove consumption, representing a cost savings of $56,000 over a three year period • A 10 per cent increase in hand hygiene compliance over a two year period The successful implementation of this new system at HDGH illustrates that great ideas can come from within the organization and that innovation does not always need to be “State of the Art” in order to be successful. By using a collaborative, inter-professional team approach, and by including front line staff in the design, an innovative point of care PPE storage system can be successfully developed and inH tegrated into practice. ■

Lindsay Samoila, Raymond Elwood and Justin Quinn work at Hotel Dieu Grace Hospital. www.hospitalnews.com

EVIDENCE MATTERS

Stitching together new evidence

on triclosan-coated sutures for reducing surgical site infections By Barbara Greenwood Dufour But the evidence is encouraging, and there was no evidence to suggest that triclosan-coated sutures lead to negative patient outcomes. If you’re interested in finding out more about CADTH’s review of triclosan-coated sutures for preventing SSIs, including its findings for other related outcomes, the report is freely available on our website. To learn more about CADTH, visit www.cadth. ca, follow us on Twitter @CADTH_ ACMTS, or speak to a Liaison Officer H in your region. ■

Barbara Greenwood Dufour is a Knowledge Mobilization Officer at CADTH.

It’s about partnership, not products. The Canadian healthcare system is constantly pushed to do more with less. The cost of disinfection Product acquisition only accounts for 10% of the total cost of disinfection. The other 90% is driven through the labour associated with the overall disinfection processes.1 REQUEST

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vention, National Institute for Health and Care Excellence, and the World Health Organization – all recommend considering the use of triclosan-coated sutures to prevent SSIs. We don’t know how much the use of triclosan-coated sutures has contributed to improvements in the rate of SSIs. And the findings from the CADTH review come with a moderate degree of uncertainty, meaning that additional research is needed for us to be more confident that these sutures lead to better patient outcomes.

NCE NA TE

Triclosan may be familiar to a lot of people. Fairly recently, it had been added to a range of household products, from hand soaps and toothpaste to kitchen cutting boards. This use has since been scaled back in light of concerns that such a wide use of antimicrobials might contribute to the development of antibiotic-resistant organisms without providing a significant benefit (e.g., triclosan-treated hand soap wasn’t found to be more effective than plain hand soap). However, the use of antimicrobials to reduce infections from surgery is quite reasonable – it’s a targeted use where the risk of infection is much higher. Although a variety of surgical products – including surgical instruments, catheters, and sutures – can contain triclosan, CADTH found research only on sutures. This newer evidence – from one health technology assessment, one systematic review, six randomized controlled trials, and one non-randomized study – strengthens the findings of the previous review. The evidence continues to, overall, indicate that that triclosan-coated sutures are associated with a lower risk of SSIs in hospitalized patients compared with uncoated sutures. In addition, there was a new study on the use of triclosan-coated sutures in children, a patient group that hadn’t previously been studied. This high-quality randomized controlled trial, which included pediatric patients undergoing general or orthopedic surgery, found that triclosan-coated sutures appeared to lower the risk of SSIs in children as well. With new evidence becoming available, new evidence-based guidelines have also been released. There were none at the time of CADTH’s previous review. The new guidelines – by the Centers for Disease Control and Pre-

TION UA AL EV

or most people, anticipating surgery is stressful for a variety of reasons. Concern that infection-causing germs will get into their incision may or may not be one of them. But, in Canada, more than 200,000 patients a year end up with a health care-associated infection while receiving care and, according to the World Health Organization, surgical site infections (SSIs) are one of the most common of these infections. There are, fortunately, measures that can be taken to reduce the risk of infection. According to a newly released study by the Canadian Nosocomial Infection Surveillance Program, these measures appear to be working. Hospital-acquired infections in Canada – one fifth of which are surgical site infections – declined by 30 per cent between 2009 and 2017. This is likely a result of the improved use of infection-control measures. Several of the measures used to decrease the risk of infection involve reducing the amount of germs in the surgical environment – on the patient, on surgical team members, and on surgical equipment. There are also medical devices and medical consumables on the market that are coated with or contain antimicrobials such as triclosan. But do these products really help reduce the risk of SSIs? A few years ago, CADTH – an independent agency that finds, assesses, and summarizes the research on drugs and medical devices – reviewed the published research on antimicrobial-treated sutures and found evidence to suggest that these products might help reduce SSIs. This year, CADTH looked for more recent information. The newer CADTH review looked for evidence on any type of single-use medical device or consumable treated with an antimicrobial, but it looked specifically for those treated with triclosan.

Reference: 1. Mullins, M. Where does the money go? A study of worker pay in Ontario’s hospitals. Fraser Institute. 2004. https://www.fraserinstitute.org/ sites/default/files/WhereDoestheMoneyGo.pdf. Accessed February 1, 2019.

FROM

OCTOBER 2019 HOSPITAL NEWS 21

INFECTION CONTROL 2019

Study shows where C. difficile is hiding in hospitals By Carrie Stefanson here are no dog days of summer for Angus and Dodger, the canine scent-detection superstars at Vancouver Coastal Health (VCH). The two super sniffers were recently reviewed by a world-renowned scent detection expert â&#x20AC;&#x201C; and passed their odour-recognition tests with flying colours. The exemplary work of Angus, Dodger and the C. difficile Canine Scent Detection Program at VCH is highlighted in the summer 2019 edition of the Canadian Journal of Infection Control. â&#x20AC;&#x153;Angus and Dodgerâ&#x20AC;&#x2122;s special talents have a tremendous impact on peopleâ&#x20AC;&#x2122;s lives by helping prevent the spread and infection of C. difficile,â&#x20AC;? says Adrian Dix, Minister of Health. â&#x20AC;&#x153;On behalf

of all British Columbians who benefit from their keen sense of smell and specialty training, we are grateful for this innovative approach to protecting patients and families.â&#x20AC;? A new study shows between May 1, 2017 and October 31, 2018 Angus and Dodger, along with their K-9 handlers Teresa Zurberg and Jaime Knowles, searched 659 clinical areas at Vancouver General Hospital. With their noses to the ground, the teams â&#x20AC;&#x153;alertedâ&#x20AC;? on C. difficile bacteria 391 times. An alert occurs when the dogs smell C.difficile and alert their handlers. The teams did not search occupied patient rooms. In 82 per cent of the cases, the dogs alerted in general areas of the hospitals including:

BIOASSURE LV WKH Č´ UVW DQG RQO\ +HDOWK &DQDGD UHJLVWHUHG SURGXFW WR GHVWUR\ ELRČ´ OPV LQ GUDLQV LQ PLQXWHV BIOASSUREâ&#x20AC;&#x2122;s IRDP IRUPXOD SURORQJV FRQWDFW WLPH LQ GUDLQV HQDEOLQJ LW WR TXLFNO\ GHVWUR\ WKH ELRČ´ OPV WKH\ FRQWDLQ DQG UHGXFH WKH VSUHDG RI VXSHUEXJV Î&#x2013;W LV GHVLJQHG WR EH XVHG DV DQ LQWHJUDO SDUW RI DQ\ FOHDQLQJ DQG VDQLWDWLRQ SURJUDP HVVHQWLDO WR DFKLHYLQJ D KLJK OHYHO RI K\JLHQH LQ KHDOWKFDUH IDFLOLWLHV Î&#x2013;Q KRVSLWDOV ELRČ´ OPV LQ GUDLQV FDQ EH D GRZQULJKW SODJXH OHDGLQJ WR QXPHURXV LQIHFWLRQV DQG GLVHDVHV 7KLV ULVN RQO\ PXOWLSOLHV LQ KHDOWKFDUH IDFLOLWLHV WKDW WUHDW SDWLHQWV ZLWK ZHDNHQHG LPPXQH V\VWHPV $V UHVHUYRLUV RI SDWKRJHQLF RUJDQLVPV ELRČ´ OP IRUPDWLRQV SRVH WKH VHULRXV ULVN RI SDWLHQWV FRQWUDFWLQJ LOOQHVVHV VXFK DV Listeria, Salmonella, E. coli, VRE, Pseudomonas, Norovirus and MRSA :HČ&#x2021;YH NQRZQ DERXW ELRČ´ OPV IRU D ORQJ WLPH QRZ EXW LWČ&#x2021;V RQO\ PRUH UHFHQWO\ WKDW ZHČ&#x2021;YH EHJXQ WR XQGHUVWDQG KRZ WKH\ DFWXDOO\ ZRUN :H QRZ NQRZ WKDW WR HOLPLQDWH D ELRČ´ OP \RX Č´ UVW QHHG WR GHVWUR\ WKH RUJDQLF PDWUL[ WR UHOHDVH WKH EDFWHULD FRQWDLQHG ZLWKLQ LW RQO\ WKHQ ZLOO WKH EDFWHULD EH YXOQHUDEOH WR GLVLQIHFWLRQ :LWKRXW GHVWUR\LQJ WKH ELRČ´ OP LWVHOI WKH EDFWHULD DQG VXSHUEXJV SURWHFWHG LQVLGH ZLOO FRQWLQXH WR SUROLIHUDWH /HDUQ PRUH DW sanimarc.com/bioassure

â&#x20AC;˘ Washrooms (public, patient and staff) â&#x20AC;˘ Hallways â&#x20AC;˘ Waiting rooms â&#x20AC;˘ Staff lockers and lounges â&#x20AC;˘ On equipment carts â&#x20AC;&#x153;The canine team alerts have confronted our presumptions of where C. difficile reservoirs lie and challenged us to re-examine the way we approach infection prevention,â&#x20AC;? says Dr. Elizabeth Bryce, Director of Infection Control, Vancouver Coastal Health. For example, the inside of a toilet-paper dispenser tested positive for C. difficile. Changing the design of the dispenser or the paper itself could reduce cross-contamination. The dogs also alerted on the tube system used to transport patient specimens. VCH purchased cleanable landing mats and reviewed the protocol for cleaning the tubes. â&#x20AC;&#x153;Every positive alert is a teaching moment,â&#x20AC;? says Teresa Zurberg, Angusâ&#x20AC;&#x2122; handler. â&#x20AC;&#x153;We work with Infection Control Practitioners to identity how C. difficile is spreading and address cleaning and disinfection practices. C.difficile is invisible and invasive, so even the most stringent cleaning might miss it.â&#x20AC;? When Angus or Dodger alert on an item, the area is thoroughly cleaned. A fleet of rapid disinfecting robots (aka

R-D) augment the cleaning process by delivering bursts of intense U-V light that eradicate antibiotic-resistant pathogens including C. difficile. Angus and Dodger are English springer spaniels trained and certified to detect Clostridium difficile or C. difficile, a superbug that attacks people whose immune systems are weakened by antibiotics. They are part of an infection prevention team that includes an Infection Control Practitioner and housekeeping staff, all dedicated to reducing environmental contamination of C. difficile. This results in a reduction in the transmission of C. difficile by healthcare workers, visitors and patients, and, in turn, a decrease in the C. difficile infection rate. While it is difficult to prove that scent detection alone reduces the spread of C. difficile, the highly visible presence of the dogs and handlers improves compliance with infection prevention measures such as hand hygiene, disinfection of personal items, and appropriate use of personal protective equipment. Since its inception in 2016, the canine scent detection teams at VCH have successfully searched hundreds of hospital areas for C. difficile. Theyâ&#x20AC;&#x2122;ve also visited 30 Canadian health care H facilities to share â&#x2013;

Carrie Stefanson is Public Affairs Leader, Vancouver Coastal Health. 22 HOSPITAL NEWS OCTOBER 2019

www.hospitalnews.com

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INFECTION CONTROL 2019

How to prevent infections at work, at home and at play

Tips to stay healthy from an infection prevention and control expert By Robyn Cox ur world is full of bacteria and viruses and our best defense is learning how to coexist with them safely as we go about our daily routines. Ina Belu is an infection prevention and control practitioner at St. Joseph’s Health Centre who advises staff on best practices for preventing and reducing the spread of infections to support a safe and healthy environment. No matter where you are – at work, at home or at play – Belu’s top tip to prevent infection is hand hygiene. “It’s important to clean your hands often, especially before eating or handling food, after using the bathroom or taking out the trash. Even if your hands don’t look or feel dirty, bacteria and viruses may still be present.”

When washing, Belu suggests using regular soap and warm water and lathering your hands for at least 15 seconds. If you’re hands aren’t visibly dirty, you can use a hand sanitizer instead. Belu recommends using a hand sanitizer with an alcohol content of least 70 per cent and rubbing your hands together until they are dry. At work, maintain a clean workspace. “Use disinfectant wipes to kill germs on surfaces, especially the keyboard, mouse, telephone and armrests,” says Belu. “Another key way to prevent the spread of infection at work is to keep up to date on vaccinations and stay home if you are feeling unwell,” says Belu. “Coming to work sick can put

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24 HOSPITAL NEWS OCTOBER 2019

Ina Belu is an infection prevention and control practitioner at St. Joseph’s Health Centre your colleagues – and patients if you work in a health care setting – at risk.” At home, Belu says to keep a general disinfectant on hand for cleaning bathrooms and kitchens. Also, ensure you’re using a different cloth or sponge in each area of the home so you aren’t transferring germs from one space to another. Antibacterial soaps are not recommended for hand and personal hygiene. Belu also shared great tips for party hosts: “If you’re serving food, consider putting a hand sanitizer at the starting

point of the food table and be sure to use dedicated serving utensils for each dish. Refrain from double dipping or sharing drinks. Likewise, don’t feel bad about cancelling if you’re sick; nothing tastes worse than a side of germs.” “Bacteria and viruses can be our friends or our foes,” says Belu. “For example, a normal bacterial flora helps with digestion and metabolism. But we need to know how to protect ourselves, our coworkers and our loved ones from bacteria and viruses that H can make us sick.” ■

Robyn Cox works in communications at Unity Health. www.hospitalnews.com

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INFECTION CONTROL 2019

Making infection prevention fun

introducing the IPAC Olympics By Amber Daugherty t’s not every day that Dianagris Balakrishnan finds herself covered in pudding at work. But one day this summer, she had so much of it on her personal protective equipment (PPE) gown and gloves that it was dripping onto the floor. The pudding had been spread by Cameron Thomas, an infection prevention practitioner, as part of an education session at St. Joseph’s Health Centre called the IPAC Olympics. Balakrishnan’s task was to remove the gown and gloves without getting any pudding on her skin or clothes underneath.

“It was gross,” the registered practical nurse says, laughing. “But it was a good reminder that there’s a lot of other stuff we could have on us when we leave a patient’s room.” The game was meant to mimic the potential for transmission of all types of bacteria by nurses and other health care providers. Walking in and out of different patients’ spaces means providers may be taking more than they’d like when they leave, potentially spreading something to other areas of the unit, other patients or themselves. This can be especially dangerous for patients with a weakened immune sys-

As part of an education session at St.Joseph’s Health Centre staff had to remove their gown and gloves without getting any of the pudding on their skin or clothes underneath. The game was meant to mimic the potential for transmission of bacteria by health-care providers. tem and during high volume times – like flu season. The PPE and pudding game was just one of four that was brought to the hospital’s 4M unit to help engage staff and visually show the significance of proper infection prevention practices. “Working in health care means you get the same information over and over again but the message gets lost because it’s always the same – clean your hands, clean shared equipment,” says Rosalyn Espiritu, the unit’s educator. “I heard that other hospitals had tried this interactive way of providing education and thought it would be impactful here because it’s new and exciting. People came over curious about why there was pudding on the table.” A common issue in health care is that people use gloves for extended periods of time, often instead of regular hand hygiene. So in another game, staff members put gloves on and had Glo Germ powder – a visual tool used in cleaning education which shows up only under UV light – sprinkled on top. They rubbed their hands together to mimic the friction of providing care and then had to remove the gloves without contaminating themselves. Thomas then used a UV light to see if any Glo Germ remained. “When I took the gloves off, I could still see some spots on my arms,” says Vina Magno, a registered nurse on the unit. “It’s so scary because normally we can’t see what’s there.” Many staff members also had Glo

Germ on their fingers and hands because of defects in the gloves. “People have a mistaken idea that gloves are impermeable and that’s why they don’t need to be as good about hand hygiene when wearing them,” says Thomas. “Staff were surprised to see powder on their hands and the reality is that Glo Germ powder is still bigger than microorganisms that could get through, which is why it’s so important that gloves be used in addition to really good hand hygiene.” Feedback on the IPAC Olympics was overwhelmingly positive from staff on 4M, so much so that other units have requested a shot at playing the games, which also included one related to cleaning shared equipment and another that tracked bacteria growth in microlab plates before and after practicing hand hygiene. The infection prevention team is exploring ways to continue this work to engage all staff members who interact with patients in a way that will hopefully stay with them. “A lot of the time, we talk in health care about the moments when you’re supposed to clean your hands but not really the why,” says Thomas. “But when you think about what you touched last and what you’re touching next, it makes a lot more sense why you should stop and make sure your hands are clean. Maybe next time someone on 4M is taking their PPE off, they’ll think about the pudding and be aware that just because they can’t see something that could potentially be harmH ful, it doesn’t mean it’s not there.” ■

Amber Daugherty works in communications at Unity Health. 26 HOSPITAL NEWS OCTOBER 2019

www.hospitalnews.com

HELP REDUCE INFECTIONS DECREASE COSTS INCREASE PATIENT SAFETY

INFECTION CONTROL 2019

Drug-resistant i on the rise By George Zhanel s we head into another season of influenza and the associated bacterial superinfections that will result, monitoring bacterial pathogens for resistance to our current antimicrobials will take on even greater importance. Antimicrobial resistance surveillance is a priority as, worldwide, we continue to witness the global public health threat of increasing antimicrobial resistance. We can also see that Canada is not immune to this rise of antimicrobial-resistant pathogens. Recently, the Canadian Antimicrobial Resistance Alliance (CARA, www.can-r.com) in partnership with Health Canada, published the results of the CANWARD study, a 10-year (2007-2016) review of trends in antimicrobial-resistant organisms identified among patients seeking care in Canadian hospitals. The eight separate medical paper supplement, published in the Journal of Antimicrobial Chemotherapy (September 2019), reviews the epidemiology of pathogens, the degree of antimicrobial resistance within specific hospital wards (medical, surgical, ICUs, emergency rooms and clinics), as well as infection sites (urine, blood, respiratory and wound).

28 HOSPITAL NEWS OCTOBER 2019

The outcomes highlight both good and bad news. Some antimicrobial-resistant pathogens (eg. MRSA) are declining in Canada, while others (eg. extended spectrum – lactamase producing Enterobacterales [ESBL], carbapenem-resistant Enterobacterales [CRE] and vancomycin-resistant enterococci [VRE]) are increasing in Canada. In addition, antimicrobial resistance and multi-drug resistance (MDR) in Pseudomonas aeruginosa continues to be a problem.

ACTION REQUIRED TO REMAIN ON THE FOREFRONT OF TREATING AND PREVENTING MDR INFECTIONS

Overall, in terms of infections caused by antimicrobial-resistant pathogens, Canada is doing better than some countries, such as the United States, but not as well as some Nordic European countries, such as Denmark, Sweden, Norway and Finland. Thus, Canada must not take its eye off the proverbial ball as infections caused by MDR and extremely-drug resistant (XDR) pathogens continue to increase in our hospitals. The worry is that as MDR and XDR pathogens continue to spread across Canadian

hospitals and cause infections, existing antimicrobial treatments will be limited and associated with greater microbiological and clinical failure rates.

HOSPITALS AND PATIENTS WILL BENEFIT FROM NEW ANTIMICROBIAL AGENTS

Canada is entering an exciting new era of treatment. While ongoing surveillance, stewardship, and infection prevention and control are imperative, so is the availability of new antimicrobials active and effective against infections caused by resistant pathogens. Canadian hospitals and patients need access to these new antimicrobials, especially those with novel, bactericidal mechanisms of action and activity against MDR and XDR pathogens. Approved treatments would ideally possess an excellent safety profile, outstanding pharmacokinetic and pharmacodynamic properties, and be available as both intravenous and oral therapies. In addition, these agents would be associated with limited resistance development during treatment, would be available to be used alone or in combination with other antimicrobials, and would demonstrate

synergistic activity/efficacy when used in combination with existing antimicrobial agents. Many new antimicrobials have recently been introduced into the Canadian market, or will soon be approved by Health Canada. These include: IV ceftolozane/tazobactam, IV ceftobiprole, IV/PO fosfomycin, IV/PO lefamulin and IV amoxicillin/ clavulanate. The challenge for medical microbiologists, infectious disease specialists, hospital pharmacy clinicians and antimicrobial stewardship programs will be identifying the patients who will most benefit from these agents and using them in a manner that optimizes their microbiological and clinical efficacy. It is important to understand that new IV antimicrobials typically receive FDA and Health Canada approval based on limited clinical trials, and as a result, the approved indications are limited. It will be common that these new IV agents will be used “off label” or “off indication”. Off-label usage, although necessitating a benefit/risk assessment, does not preclude an effective clinical outcome. Canadian hospitals need to continue their focus on what they do best – surveillance of antimicrobiwww.hospitalnews.com

INFECTION CONTROL 2019

t infections al-resistant al-r al -rres esis sis isttant tantt ppathogens, a ho at hoge gens, an antimicronttiimi micr croobial bi iall stewardship, ste tew ward ward rdsh ship sh ip,, and ip and infection in nfe fect ctio ct ion n preprepr evvention ve ent n ioon and and control. control At co At the th he same s me sa time, we are heading into a new era of agents that will help hospitals to treat their patients. This is welcome news as antimicrobial-resistant and MDR infections increase. For the first time in many years we will have several new IV agents developed to target MDR infections. As a next step, hospitals will need guidance on the use of new antimi-

will difficult ccrobial cr obia ob iall ag aagents. gen nts. ts. It ts It w ill il ll be b ad iffi if ficu fi ccu ult bbalallancing an nci cing ng act ng act c for for Canada Can nad ada to assure ass ssur ure that ur that antimicrobial an nttiimi micrrob obia iall stewardship ia stew st ewar ew arrdshi dshi hipp programs prog ogra og raams are aware of when, and how, to use new antimicrobials in patients with infections caused by difficult-to-treat and antimicrobial-resistant pathogens. Canada will also need a national registry for clinicians to share their clinical experiences â&#x20AC;&#x201C; documenting when, how and why they use these new IV antimicrobials, as well as their effectiveness and safety.

As antimicrob antimicrobial-resistant infections continue to ris rise in canadian hospitals, surveillance, in infection prevention and control, stewar stewardship and the availability of new antimic antimicrobial agents will keep us at the forefront of treatment and prevention. ti

Knowing the impactful work conducted by Canadian hospitals in the areas of surveillance, infection control and prevention, and stewardship, we should be confident that Canada will remain at the forefront of treat-

ment with new antimicrobial agents. Strengthening our response to the increase in drug-resistant infections H is the best medicine! â&#x2013;

George Zhanel is Professor-Department of Medical Microbiology and infectious Diseases, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba and Director-Canadian Antimicrobial Resistance Alliance (CARA, www.can-r.ca).

MARKETPLACE SPOTLIGHT

Researching the

biomarkers of suicidality By Mary Dickie very day in Canada, an average of 10 people die by suicide, and as many as 135 others are profoundly affected by each suicide loss. And

yet we don’t know how to accurately predict suicide, or even how to fully characterize it. Why do some depressed people contemplate suicide constantly and

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30 HOSPITAL NEWS OCTOBER 2019

others never even consider it? What does the brain of a suicidal person look like, compared to the brain of someone who’s depressed, but not suicidal? Could understanding these differences lead to new ways to treat depression and prevent suicide? These are the questions that preoccupy Dr. Sakina Rizvi, a scientist at the Arthur Sommer Rotenberg Suicide and Depression Studies Unit at St. Michael’s Hospital. Dr. Rizvi’s project, The Biomarkers of Suicidality, was recently chosen as the second recipient of a $190,000 research grant from St. Michael’s Research Innovation Council (RIC), a group of St. Michael’s Foundation donors who pool their funds, evaluate research applications and select high-potential projects to support.

“The World Health Organization reported that mental health disorders account for the majority of disability globally, but only a small percentage of research funding,” she says. In fact, Dr. Rizvi’s is the only program doing this kind of work in Canada. “I think it’s something that people have a hard time looking at,” she explains. “It’s not visible, and there’s still a lot of stigma around it.” Dr. Rizvi’s research background is in treatment-resistant depression, studying patients who’ve tried multiple therapies. “Of course I’d worked with research participants experiencing suicidality, but I’d never looked at it as its own entity,” she explains. “Once I started, I was shocked to find how little neurobiological research had been done. I

THE WORLD HEALTH ORGANIZATION REPORTED THAT MENTAL HEALTH DISORDERS ACCOUNT FOR THE MAJORITY OF DISABILITY GLOBALLY, BUT ONLY A SMALL PERCENTAGE OF RESEARCH FUNDING, The RIC funding will help Dr. Rizvi expand her research from a pilot to a much larger study. She says she’s excited and thankful, albeit a bit surprised, since despite suicide’s devastating impact on society, it doesn’t get the funding that other major illnesses receive.

think it’s partially because suicide risk is seen as a symptom of a mental illness as opposed to something on its own.” She says in her research about half of treatment-resistant patients seem to be more at risk of suicide, and she wants to know why. www.hospitalnews.com

MARKETPLACE SPOTLIGHT “Even with all else being equal, there’s something different about the group that will actually make a suicide attempt,” she says. “That’s why research like this is so important, because we don’t really know who they are. For a clinician, it’s very challenging to identify the person who is likely to make an attempt and needs intervention.” With RIC support, Dr. Rizvi’s project will focus on two areas: understanding the neurobiological mechanisms behind suicide, and integrating what’s already known about it into a cohesive model so new treatments can be developed. That’s why Dr. Rizvi is examining not just the biology of a patient’s brain – including activity across brain networks – but also their psychological risk factors and social determinants. “It’s a mistake to look at biology in isolation, because we’re not just biological beings,” Dr. Rizvi explains. “I try to put it into context. The different pieces interact with each other. It’s important to understand how it all works

DR. RIZVI’S PROJECT WILL FOCUS ON TWO AREAS: UNDERSTANDING THE NEUROBIOLOGICAL MECHANISMS BEHIND SUICIDE, AND INTEGRATING WHAT’S ALREADY KNOWN ABOUT IT INTO A COHESIVE MODEL SO NEW TREATMENTS CAN BE DEVELOPED. together if we’re going to be able to make treatments that impact people’s lives.” Dr. Rizvi will scan the study participants’ brains to look at their structures and connections, memory and attention resources, and how they respond to rewards and to pain. “There might be differences in brain volume in areas that are important for emotion regulation and decision making. There might be differences in certain neurotransmitter systems, in how the brain is connected,” she says. “We are starting to see some of those differences, but we’re not anywhere near the point where we can look at a

scan and say, ‘That’s a suicidal brain’ – and that’s why we need to do more research.” Dr. Rizvi says that people at high risk for suicide tend to have difficulty focusing their attention, don’t experience rewards as positively as others do, and have higher levels of psychological pain and, interestingly, higher tolerance of physical pain. Why? “My hypothesis is that psychological pain overburdens the neural resources normally dedicated to focal attention,” she says. “The pain is recruiting pathways and areas of the brain needed for attention, so people don’t have the resources left to pay attention to

things that might otherwise be attention-grabbing, like physical pain or rewards. I’m looking at the interaction of how we pay attention to things, how we find things rewarding and how we experience pain, and in what ways that can lead to increased suicide risk.” A neuroscientist by training, Dr. Rizvi believes that researchers also have a responsibility to do advocacy and mental health education, which is why, along with her work exploring suicide, she volunteers as a grief counsellor for suicide loss survivors. “It’s humbling to sit with somebody in that pain and help them work through the devastating effects that kind of loss has,” she says. “Suicide doesn’t affect just one person, it affects communities and generations, and people are not paying enough attention to it. That’s why funding like this grant from the Research Innovation Council can go so far. It helps to run the study, and also to recruit the research talent who can build capacity in this area and really H push it forward.” ■

Mary Dickie works in communications at Unity Health.

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OCTOBER 2019 HOSPITAL NEWS 31

MARKETPLACE SPOTLIGHT

The

war

against

nicotine

By David T. Sweanor J.D. t has become a common coffee shop experience to get engaged in discussions concerning opioid and nicotine addictions, given all the frightening stories on overdoses and vaping. We wonder what can possibly be done to reduce the reported harms. After all, as we sip our lattes and cappuccinos; maybe a double espresso if we feel the need, we all have attitudes about addictions. Often, while possibly getting our cup refilled, we acknowledge that we cannot understand what could cause someone to use drugs. Maybe if we just did more to punish, ostracize or

32 HOSPITAL NEWS OCTOBER 2019

otherwise coerce those opioid or nicotine users we’d solve the problem. Well, coercion has certainly long been practiced in battling drug use. In fact, no less an authority than Murad IV had users of a particular drug flogged, with repeat offenders being sewn up in bags and thrown into the Bosphorus River. Sweden’s King Gustav III sentenced a condemned man to use this drug every single day until it killed him*. Frederick the Great condemned the drug as a threat to national security. Don’t even get me started on the English reaction to it . . . The drug in question? Coffee.

Wars on drugs have been waged on and off for a very long time. Never won, just waged, and at an enormous social and health cost. But just as the war on alcohol, known as Prohibition, abated we got a war on narcotics that became a general War on Drugs. Prohibition was a public policy disaster; the War on Drugs is a social and public health catastrophe. So why stop now? As policy finally moves toward far more humane approaches to the users of drugs from opioids to cannabinoids, we have a whole new drug war emerging. One that is, like the past ones, based on manufacturing a mor-

al panic, playing fast and loose with the truth, and inflicting huge harm on public health, consumer rights and the rule of law. Welcome to the War on Nicotine. This is, to put it mildly, an odd war. We have known at least since the ground-breaking work of Professor Michael Russell in the 1970s that people smoke for the nicotine but die from the smoke. As seen with nicotine pharmaceutical products and through very long-term use of an oral tobacco product called ‘snus’ in Sweden, nicotine can be delivered with minimal risks once the smoke and ancillary www.hospitalnews.com

MARKETPLACE SPOTLIGHT toxins are removed. What we have is akin to trying to deal with cholera not by removing the fecal contamination but by attacking the drinking of water. Essentially, we just need to focus on getting the crap out of the delivery system. Such prestigious bodies as the UK’s Royal College of Physicians, which also led the world in detailing the ravages of cigarette smoking in 1962, states that vaping is ‘likely to be at least 95 per cent less hazardous than smoking’. That is not perfect, but it beats even what has been accomplished in auto safety since the Swedes led the way on three-point seatbelts. In fact, the Swedish efforts on automobile and tobacco risk reduction go back to the same time and the companies in question were owned by the same government entity. A good measure of how nicotine came to be seen more as the sort of moral issue that gets us the social panics that lead to drug wars, is that we praise vehicles like Volvos for the transition they lead to far few-

VAPING PRODUCTS ARE SUBJECT TO SEEMINGLY UNENDING SCARE STORIES THAT STRAY A VERY LONG WAY FROM FACTS AND AVOID REFERENCES TO RELATIVE RISKS OF CIGARETTE SMOKING. er road fatalities. But the snus they try to sell to Canadian smokers has higher taxes than lethal cigarettes, get covered in frightening but inaccurate health warnings, and if they opted to tell Canadian smokers about the difference in risks our federal tobacco legislation stipulates they’d face jail time. Vaping products are subject to seemingly unending scare stories that stray a very long way from facts and avoid references to relative risks of cigarette smoking. For anyone familiar with Reefer Madness, this looks like a remake. While the approach we have taken to date on nicotine might make for a good Kafkaesque theatre production, it is tragic public health policy.

Sensible regulation could rapidly replace cigarettes with ever less toxic and addictive alternatives. We have, after all, used such risk reduction approaches to massively reduce the harms of foodstuffs, pharmaceuticals, medical procedures, building standards, industrial accidents, auto injuries, air pollution and a very long list of other products, services and behaviours. Public health need not be complicated. Where we find risks, we seek to reduce them. We do so by empowering people to make better health decisions. We ‘nudge’ healthier behaviours. Well, we also make use of my profession to sue-into-oblivion the corporate laggards.

Health professionals can look for guidance in dealing with patients from bodies such as the UK’s National Health Service, Royal College of Physicians or Public Health England (US entities have a poor track record on issues with moral overtones). Most importantly, focus on getting people off, and keeping them off, cigarettes. Let them know it is the smoke, not the nicotine, that will kill them; just as we would see if they were smoking rather than brewing tea leaves to get caffeine. In dealing with our leading cause of preventable death perhaps we each need a simple four word sign: ‘It’s the Smoke, Stupid’. Effective action means acting pragmatically; discarding some often deeply entrenched ideological or moral views about what other people do. That might not for some of us be as satisfying as behaving like modern day Murads, but it would be a huge breakthrough for public health. *The king and the jailers died H first. ■

David T. Sweanor J.D. is Chair of the Advisory Board, Centre for Health Law, Policy & Ethics, University of Ottawa; Adjunct Professor, Faculty of Law, University of Ottawa; Legal Counsel, Non-Smokers’ Rights Association, 1983-2005 and Recipient, Outstanding Individual Philanthropist Award, Ottawa, 2016.

MARKETPLACE SPOTLIGHT

E-cigarettes: Harm reduction or harm? cigarettes or ENDS, electronic nicotine delivery systems, have been on the market for over a decade. They’ve been touted as a harm reduction strategy for cigarette smokers, becoming a linchpin in the British National Health Service’s tobacco cessation efforts. This summer, ENDS headlines have been less positive, with US data showing a large increase in teens who regularly use ENDS, commonly referred to as vaping, reversing a previously declining trend in US adolescent nicotine initiation. Adolescent vaping in Canada has not seen as sharp an increase to date though available data precedes the new e-cigarette legislation of May 2018, and prevalence rates are highest among young adults . Even more worrisome, are the now seven deaths and over 500 cases

of vaping-related lung illness linked to vaping in the US, mostly in younger users with few to no co-morbidities. While long term studies on human health aren’t yet available, a recently published study on vaping in mice may offer some clues on what we can anticipate and to the recent outbreak of vaping-related lung illness. In that study, Madison et al found mice exposed to ENDS vapor, compared with those exposed to tobacco smoke, had increased lipid deposition and decreased immunity against viral pathogens in their lung cells (macrophages and epithelial cells), resulting in worse lung inflammation and tissue damage when subsequently infected with influenza virus. These results were seen in mice exposed to ENDS vapor regardless of nicotine content pointing to the need for further study of the health effects

Mental Health and Health Care Workers At some point in their careers, medical laboratory professionals have experienced work-related stress, directly impacting their mental well-being. For these professionals, and others working in health care, depression is 5% higher and anxiety is 2.7% higher than the general population.1 The Canadian Society for Medical Laboratory Science (CSMLS) ZDV ÀUVW WR FRQGXFW D ODUJH VFDOH VWXG\ GHWHUPLQLQJ WKH VWDWXV of mental health within the medical laboratory profession. The study revealed a surprising 59% of participants experienced high levels of stress at work at least once or more daily. 76% felt burned out weekly, if not daily, due to work stressors.2 To support members, the CSMLS created the Mental Health Toolkit. This bilingual online resource provides lab professionals with the means needed to identify, monitor and implement change in mental wellness. “We created the toolkit with our members in mind, medical laboratory professionals,” says Christine Nielsen, CSMLS CEO. “However, we made it available to everyone because we NQRZ WKDW DQ\RQH ZRUNLQJ LQ KHDOWK FDUH FDQ EHQHÀW IURP WKH information.” The award-winning toolkit is web-based and accessible for free. It is a starting point for accessing information, support services and management for mental health issues.

FOR PATIENTS ALREADY VAPING, DISCUSSING WHAT THEY ARE VAPING IS KEY TO OFFERING ADDITIONAL SAFETY INFORMATION WITH THE RISKIEST PRODUCTS CURRENTLY THOUGHT TO INCLUDE FLAVORED LIQUIDS, NONCOMMERCIAL PRODUCTS, AND THOSE CONTAINING THC. of various solvents being used in vaping products. With more research on the short and long term health effects of ENDS needed, healthcare providers should strive to establish and keep an open and ongoing dialog with their patients about vaping, starting with screening for ENDS use, providing a brief, supportive statement about not initiating vaping behavior for those screening negative, and offering alternative tobacco cessation strategies to current tobacco users who are considering vaping for their next quit attempt. For patients already vaping, discussing what they are vaping is key to offering additional safety information with the riskiest products currently thought to include flavored liquids, noncommercial products, and those containing THC. Avoiding these

may limit harms. Patients who are vaping should be asked about any current or recent pulmonary symptoms including cough and shortness of breath, and encouraged to seek early diagnosis and care if those symptoms should arise. For vaping patients with those symptoms, prompt and thorough assessment is warranted, and vaping-related lung illness should be included in the differential diagnosis. If available, samples of recently vaped products should be gathered for further testing. With the well-known and overwhelmingly negative health impacts of long term tobacco use, the use of ENDS as a harm reduction strategy for current tobacco users may well end up being supported by longer term studies. ENDS use by youth and in non-tobacco users may not be H as low risk as hoped for. ■

Visit the toolkit at

mentalhealth.csmls.org Reference 1. https://www.csmls.org/Research/Projects,-Reports-Presentations/Special-Initiatives.aspx 2. https://csmls.org/csmls/media/documents/resources/mentalhealth.pdf

34 HOSPITAL NEWS OCTOBER 2019

www.hospitalnews.com

MARKETPLACE SPOTLIGHT

Your inner voice can save lives:

#ConquerSilence with Canadian Patient Safety Week Contributed by the Canadian Patient Safety Institute f something looks wrong, feels wrong or is wrong, speak up in the moment. Conquer Silence is the theme of Canadian Patient Safety Week 2019. A new website, www. ConquerSilence.ca will launch on October 21, 2019, where patients, providers, health administrators, policymakers and the public can share stories and advice on how to reduce patient harm. Every single year 28,000 Canadians die from preventable harm when receiving care. This makes patient safety incidents the third leading cause of death in Canada, behind cancer and heart disease. One in three Canadians has had patient harm affect themselves or a loved one, yet collectively

EVERY SINGLE YEAR 28,000 CANADIANS DIE FROM PREVENTABLE HARM WHEN RECEIVING CARE. the public is unaware that the problem exists. That is the silent epidemic. If we do nothing, 1.2 million Canadians will die from preventable patient harm over the next 30 years. Now in its 15th year, Canadian Patient Safety Week will be celebrated from October 28 to November 1, 2019 to help make patient safety a priority. A new episode of the award-winning PATIENT podcast series asks patients, providers, and leaders how they are conquering silence and what we can do to stay safe. Two new we-

binars will take place during Canadian Patient Safety Week: a webinar for healthcare providers to learn how they can #conquersilence, and how they can lead a workplace culture to do the same; and a Mandatory Reporting webinar focusing on the new requirements for hospitals to report serious adverse drug reactions and medical device incidents under the Protecting Canadians from Unsafe Drugs Act. Tools and resources are now available at www.patientsafetyweek.ca, along with a Communica-

tions Toolkit on how to promote the week on social media and how to improve patient safety. The Canadian Patient Safety Institute website hosts a series of 34 videos that showcase the great work happening in healthcare through the human-interest stories that profile patient safety champions and what they do to improve patient safety. These personal stories of heartache, loss, and frustration due to unsafe care are inspirational and a great motivator to improve the quality of healthcare in Canada. Last year, almost 1,500 registrants signed up to participate in Canadian Patient Safety Week. Visit www.patientsafetyweek.ca to register and to order a free #ConquerSilence promotionH al package – you pay only for shipping. ■

Canadian Society for Medical Laboratory Science Société canadienne de science de laboratoire médical

CSMLS Mental Health Toolkit

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By the time Canadians reach 40 years of age, 1 in 2 have or had a mental illness. The CSMLS Mental Health Toolkit: ƌɄ

Provides access to tools & information to monitor mental health and foster positive change for mentally healthy workplaces

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Has designated areas for managers, students and employers

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Is available in both English and French as a free resource

mentalhealth.csmls.org www.hospitalnews.com

OCTOBER 2019 HOSPITAL NEWS 35

MARKETPLACE SPOTLIGHT

Steve Myers went from wanting to end his life, to inspiring others to seek help for their mental illness.

A road to recovery

from depression and anxiety By Nikki Jhutti e’s a familiar face in the halls of Providence Care Hospital. As a volunteer, Steve Myers helps out at the welcome desk, in the café and he even gives guided tours of the hospital. If someone is in need, the 54-yearold is the type of man to lend a helping hand. But eight years ago, he was the one in need. In March 2011, Myers seemingly had it all; a loving wife and family, and a great job as a restaurant manager.

36 HOSPITAL NEWS OCTOBER 2019

ANXIETY AND DEPRESSION TAKE LIFE’S ENERGY AWAY But that didn’t stop depression from creeping in. “Things were going really, really good, but I was afraid I couldn’t keep exceeding,” recalls Myers. “I didn’t want my family or employees to see me fail.” Myers decided he would take his own life. “I woke up one morning, waited for my wife to go to work and my sons to go to school, and I decided

I was going to get out while the going was good.” Myers was unsuccessful, but that didn’t stop him from trying again. “I tried to take my life 10 times in eight years. Seven of those times were within the first two years.” Myers’ illness got worse. He developed anxiety on top of his depression. “I’m the kind of person that

doesn’t like to ask for help or share my feelings. I ended up isolating myself at home. I was embarrassed what people would think when they found out I tried to take my life and failed.” During a stay at Kingston General Hospital, Myers was referred to Providence Care’s Community High Intensity Treatment Team. A dozen highly skilled and dedicated clinicians supported Myers, including Dave Carmichael, an Occupational Therapist with Providence Care. “Anxiety and depression take life’s energy away,” explains Carmichael. www.hospitalnews.com

MARKETPLACE SPOTLIGHT “Steve is an amazing and courageous person. He is also a very anxious human being, so we had to build that therapeutic relationship.” It started with Carmichael visiting Myers in his home, for coffee. “He would come at least once a week. At times we wouldn’t even talk. We would just sit there,” recalls Myers. “He just kept coming and eventually I started opening up to him.” But recovery takes time. It took two years before Myers was willing to leave his home. The pair decided to meet for double doubles at a local coffee shop. But Myers was still anxious. “I was worried about running into someone I knew and being asked ‘how are you doing?’ or ‘what are you doing now?” “A large part of what we were doing was finding suitable explanations for Steve,” adds Carmichael. “We were working through role plays, how to explain oneself, saying things like ‘I’m not working, but here’s what I am doing.”

MYERS QUICKLY LEARNED HE COULD MANAGE HIS ANXIETY IF HE CONTROLLED CONVERSATIONS. Myers quickly learned he could manage his anxiety if he controlled conversations. “I would initiate a conversation with a ‘how are you?’ so they couldn’t ask me ‘what are you doing now?’ or ‘how are you feeling?” “Initially it was about helping Steve push the boundaries with his anxiety, so that he could get out of the house,” explains Carmichael. “Then it was helping Steve set goals. These are all Steve’s goals, not Dave’s goals. So we’re moving at Steve’s pace and in a direction Steve wants to go.” It would be another two years before Myers would be ready to take the next step with Carmichael: visiting his old restaurant. “I knew I was going to a place where people knew me, and possibly even

knew what I had attempted,” says Myers. “But I did it. And some people were surprised to see me and happy to see me.” Myers started volunteering with Providence Care in January 2018. “It’s a safe working environment. I’m not afraid if someone comes through that door, what they think of me because there is no judgement here.” In addition to his weekly meetings with Carmichael, Myers also takes medication daily and he sees his psychiatrist once a month. “He’s the type of client every clinician lives for. This is a man who couldn’t leave his house. He now leaves his house at will and he’s thoroughly exploring his wish to help other people,” says Carmichael.

Myers also credits his family for their support and sticking by him. “I think I’m more focused on my family than I ever was. My wife says I am the most important person in her life and she would be devastated if I were to go. She really likes the person I have become.” His advice for others who may be struggling with depression or anxiety: confide in someone you trust. “Try to share your feelings with your family or friends. It’s what I should have done.” It’s been hard work, but Myers says he’s improving every day. Even opening up and sharing his story for this article was a big step for the 54-year-old. “I’m not as embarrassed anymore. I have an illness and I have people I can count on for my illness.” But the work isn’t done. Myers hopes the experience he’s gaining from volunteering at Providence Care will help him with his next H goal: to reenter the workforce. ■

Nikki Jhutti works in communications at Providence Care.

Student Testimonial Not only does McMaster University is a research-intensive institution, but it also provides a supportive environment to help students to pursue career goals as a clinician scientist. The dual MSc. (Occupational Therapy)/ PhD (Rehabilitation Science) allows me to conduct my research in cancer rehabilitation and learn about how occupational therapy addresses the needs of cancer survivors during my professional OT program concurrently. With the great support from Dr. Jackie Bosch (My Supervisor), Dr. Julie Richardson (Assistant Dean of School of Rehabilitation Science) and my committee, I have the opportunities to join the world-renowned multidisciplinary teams in an international multi-center study; and attend national conferences to develop professional networks. They are dedicated to address my learning needs as a direct Ph.D. student and help me succeed. Their continued support has allowed me to leverage my leadership skills and collaborate with clinicians and investigators at the Princess Margaret Cancer Centre to advance my research potential. This program will be an ideal fit for me to develop the knowledge, skills, and attitudes of a competent and compassionate clinician scientist. Name: Vanessa Fan (Dual OT/PhD Candidate, HBSc.) Supervisor: Dr. Jackie Bosch www.hospitalnews.com

OCTOBER 2019 HOSPITAL NEWS 37

ETHICS

Ethical issues of

cryonics By Kristina Smith and Andria Bianchi ase: Sasha is a 60-year-old neurologist and researcher who is interested in concepts of life, death, and consciousness. Sasha is aware of the ethical complexities that can arise in relation to death determinations, the most common of which is that some people may not recognize brain death as a legitimate type of death (as noted in a previous column). In his recent readings about death and consciousness, Sasha discovered a practice that is referred to as cryonics; this is when a person is declared legally dead, yet their body is preserved by cooling it to a liquid nitrogen temperature so that any further decay is halted. The goal of cryonics is to enable cooled bodies to regain consciousness in the future as a result of anticipated scientific advances. After much contemplation, Sasha decides that he wants to undergo cryopreservation once he is declared dead. He registers with a cryopreservation lab so that they can support his body’s preservation. In order to ensure that this autonomous wish is respected, Sasha develops an advance care plan which states that: (1) if he has a heart attack then he wants all measures to be taken to keep his body alive until cryonics staff arrive and can transfer his body to their laboratory and/or (2) if he is declared dead then he wants his body to be immediately cooled so that there is still a potential for cryopreservation. As mentioned above, the goal of cryonics is to preserve a person’s body after they are declared dead with the goal of reviving it through future scientific advances. Robert C. Ettinger originally introduced the idea of cryonics in his 1962 book The Prospect of Immortality. In his book, Ettinger

38 HOSPITAL NEWS OCTOBER 2019

THE GOAL OF CRYONICS IS TO PRESERVE A PERSON’S BODY AFTER THEY ARE DECLARED DEAD WITH THE GOAL OF REVIVING IT THROUGH FUTURE SCIENTIFIC ADVANCES. says that most human beings “have a chance for personal, physical immortality” since, at very low temperatures, biologically dead bodies (namely, corpses) can be preserved with minimal deterioration. And if corpses can be preserved, then irreversible death may be preventable if science learns to revive these bodies and to cure them from diseases that may have previously influenced their death. Ettinger uses the term “suspended death” to refer to

a dead body that has been frozen and preserved. The purpose of Ettinger’s book is to argue for the potential to achieve immortality. At the start of his book, he says that his goal is to show that: (1) immortality is attainable; (2) immortality is practical and does not raise any overwhelming new problems (since a revived person will resume life as per usual) and; (3) immortality is desirable.

Regardless of whether new obstacles arise, however, it seems inevitable that some significant ethical questions and issues will occur when it comes to practicing cryonics. For instance, if a person has been pronounced dead and their body is being preserved (and if the person may become conscious in the future), then will they continue to maintain rights (e.g., the rights that are associated with being a citizen)? Relatedly, is the deceased (cryonics) body considered to be a person? Some theorists suggest that persons have certain traits and characteristics, such as being able to think or communicate in a particular kind of way. So, depending on one’s conception of personhood, then it seems as though a corpse may or may not be considered a person and www.hospitalnews.com

ETHICS their rights will differ depending on how they are classified. Furthermore, how should a revived personâ&#x20AC;&#x2122;s family treat them and what would their obligations be? For instance, would a family member be financially responsible for the revived person? Another concern that influences all of society is that of resource allocation. Given the scarcity of resources that currently exist in our medical system, it is worth asking how many and what kinds of resources should be allocated to a dead body. Is it ethically defensible to contribute medical, social, and other resources to a person declared dead? Relatedly, if a person is revived, then should they be allocated as many healthcare (and, perhaps, other) resources as individuals who have contributed to society in recent years? In regard to the above case, one might ask whether it would be fair to provide Sasha with scarce healthcare resources in order to maintain his life post-cryo-

IS IT ETHICALLY DEFENSIBLE TO CONTRIBUTE MEDICAL, SOCIAL, AND OTHER RESOURCES TO A PERSON DECLARED DEAD? preservation? Some people may argue that Sasha has already had his fair share of resources allocated to him; no more resources ought to be provided to cryopreserved bodies post-revival. These resource allocation questions are classified under the category of distributive justice, which considers what fairness means when it comes to distributing resources. Another ethically relevant concern is the rights and, perhaps, the dignity of the healthcare team. If a healthcare team member does not agree with the practice of cryopreservation because they think that it is immoral, then should they be involved in caring for someone like Sasha? Should

they be allowed to exercise their right to refuse to provide treatment to Sasha on moral grounds (in other words, conscientiously object)? The dignity of the person is also an ethical concern. For example, if Sasha were successfully revived 50 years into the future, would he have family and/or friends to care for him? If not, then would he be able to live a quality of life that is meaningful and promotes happiness? Finally, it is important to consider the principle of non-maleficence (that is, to do no harm) when considering the family members of a cryopreserved person. By preserving their loved one and maintaining hope that they may be successfully

revived, a family may be less able to move on with their own lives and accept death, which may potentially cause unnecessary suffering. Given current and ongoing scientific advancements, cryonics is an important issue that deserves increased attention. Cryonics presents a unique case for the medical system and society, with the prospect of preventing a permanent death. However, it is necessary to carefully consider the multi-dimensional impacts of suspending death, and how the potential negative outcomes of cryonics can be mitigated. Several ethical concerns have been illustrated in this short article, in part, to promote a larger dialogue around the possibility of immortality. Although cryonics is not yet practiced globally, it is increasingly attracting more clientele, and as a result, there is an ethical obligation to carefully consider the potential positive and negaH tive consequences. â&#x2013;

Kristina Smith is a PhD Candidate in the Faculty of Kinesiology and Physical Education, and is completing a collaborative degree with the Joint Centre for Bioethics at the University of Toronto. Andria Bianchi, PhD, is a Bioethicist at the University Health Network

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OCTOBER 2019 HOSPITAL NEWS 39

FROM THE CEO’S DESK

Reacting to real-time data is too late By David Musyj uring the lead up to the most recent provincial election and afterword, we have heard plenty of discussions regarding “Hallway Medicine” and the need for it to end for the benefit of our patients, staff members and community. There has been some instructive reports written about the causes and possible solutions to ending this issue by the Premier’s Council on Improving Healthcare and Ending Hallway Medicine. One of the issues highlighted in the second report of the Council is

40 HOSPITAL NEWS OCTOBER 2019

the creation of a Command Centre that “uses real-time data, advanced algorithms, predictive analytics and adherence to operating procedures to ensure timely, seamless treatment for patients. The centralized team staffing the Command Centre are able to quickly address patient care delays in an efficient and coordinated way.” Windsor Regional Hospital (WRH) is one of the largest community teaching hospitals in the province with approximately 575 beds divided between two hospital campuses. In October 2017, WRH opened Command

Centres at each of its two acute care campuses. The Command Centres are open 24/7 and coordinate all patient flow. Both campuses combined have fewer than 20 per cent private rooms and are home to some of the oldest infrastructure in the Province of Ontario. At least twice a day, and up to four times a day during influenza season, the clinical and non-clinical teams attend the Command Centres to discuss and address any real-time issues with the use of OTN but also, more importantly, use predictive data to plan for future patients who will require acute care in the next 12-24-36-48-96 hours

and beyond. If we are addressing real-time patient flow issues, we are actually “too late”. The Peter Drucker statement, “you can’t manage what you can’t measure,” is displayed at both Command Centres above the electronic displays. In 2016, Windsor Regional Hospital recognized the need to end Hallway Medicine and that it would not end without positive changes. In 2016, each day, WRH was facing the following: • Twenty-four (24) “admit no bed” patients a day. These are patients who have been admitted but are waiting www.hospitalnews.com

FROM THE CEO’S DESK

IF WE ARE ADDRESSING REAL-TIME PATIENT FLOW ISSUES, WE ARE ACTUALLY “TOO LATE”. in the Emergency Department for a bed to become available; • Thirty-eight (38) patients a day being placed “off-service” even after moving to an inpatient floor; • In-patient beds remaining empty 5-12 hours after a patients were discharged; • Actual length of stay one day longer than expected; • Discharge rates on weekends a third lower than during the week; and • Time to inpatient bed after admission was 11 hours. In order to tackle these issues, WRH not only created the Command Centres, but also examined prior patient data for each service to predict dayby-day, program-by-program, floor-byfloor, the exact number of admissions expected, be it medicine or surgical, elective or emergent, and the needs required by the system.

We also used simulation software and queuing theory to take the “magic” out of healthcare and the typical “we have no clue what is coming through our doors” explanation. Pretty much, we know how many patients to expect each day by the time of day, what they are going to present with and in some circumstances, the name of the patient expected to attend. Key components was the creation of “assessment bays” to pull admitted patients from the ED to a temporary spot while they are awaiting the carbolization of their inpatient bed. The goal is to have the assessment bays empty. In addition, we track what is called “grey days.” These are days that are tracked for any one of our approximate 600 patients who have their stays extended due to us not fulfilling

David Musyj an order for any testing (i.e. diagnostic or otherwise). Twenty-four months after implementation, the current results show marked improvements: • The average number of “admit no

bed” patients waiting in ED has been reduced from 24 to 4; • The average number of patients being placed “off-service” each day, even after moving to an impatient floor, has been reduced from 38 patients a day, to 5; • Inpatient beds, which used to remain empty for 5-12 hours after patients were discharged, are now carbolized immediately after discharge; • The average length of stay (LOS) for patients used to be 1 day above the expected LOS, is now actually at or lower than the expected LOS; • Discharge rates, which used to be a third lower on weekends have equalized; and • The average wait for an inpatient bed after admission has been reduced from 11 hours to 3.2 hours. These results take a whole team effort and they will ensure WRH is prepared for any surges by not only allowing us to predict them in advance, but avoid or greatly reduce Hallway H Medicine. ■

David Musyj is the President and CEO, Windsor Regional Hospital.

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OCTOBER 2019 HOSPITAL NEWS 41

NEWS

Karim Mamdani, President and CEO of Ontario Shores Centre for Mental Health Sciences, launched the hospital ‘Celebrating a Century of Care’ campaign to recognize 100 years of providing care to people living with mental illness.

Ontario Shores

celebrates a century of care By Melissa Quinlan ntario Shores Centre for Mental Health Sciences (Ontario Shores) is celebrating 100 years of helping individuals living with mental illness. The organization’s journey officially began in 1911 when architect James Govan consulted with psychiatrists, physicians and government officials to develop a design for a new mental health centre on the shores of Lake Ontario. During World War I it served temporarily as the Ontario Military Hospital, a convalescent home for wounded veterans before shifting back to mental health and officially opening as the Ontario Hospital for the Insane on October 23, 1919. The hospital has had several names over the years and in 2009 rebranded to Ontario Shores. For the past century, Ontario Shores has provided psychiatric health care for people living with complex mental illness. The hospital has re-

42 HOSPITAL NEWS OCTOBER 2019

mained on the same grounds for the last 100 years, allowing patients to enjoy a therapeutic environment of recovery on the beautiful shores of Lake Ontario. The organization has seen transformations in a number of areas over the last 100 years, particularly in recovery, to improve the lives of people living with mental illness. In the early 2000s, Ontario Shores embraced a philosophical shift in focus of care, pushing for personal recovery distinct from clinical based on the principles of empowerment, hope, recovery, collaboration, identity, responsibility and meaning in life. Notable advancements have been implemented since the shift in care including a HealthCheck Patient Portal that brings balance to the patient-clinical relationship, allowing individuals to be in control of their path to wellness. The Portal enables enhanced patient monitoring and provides clinicians with real-time access to critical health

information necessary to provide safe and quality care. Innovation has grown exponentially in the area of technology with the organization’s use of electronic medical records. In 2014, Ontario Shores became the first hospital in Canada and the first mental health hospital in the world to achieve the prestigious HIMSS EMRAM Stage 7 Award – having a completely paperless health information system which advances the use of patient data to ultimately improve process and performance. The hospital implemented the Recovery Action Plan to identify opportunities to advance its recovery efforts. It consists of a wide array of plans such as establishing the first Recovery College in the inpatient hospital setting in the world, as well as the first Recovery College in Canada. Recovery College administers courses that provide education about mental illnesses, treatment options, wellness and ultimately discovering or rediscovering passions, hope and meaning.

The hospital has expanded its services to outpatients with 90,000 visits annually. Outpatients receive care and support to reach their goals aimed at independent or group living back into the community. Ontario Shores provides a number of outpatient programs as well as partnerships with other organizations to provide patients with wellness, vocational skills, literacy and independent living training and support to adolescents, adults and seniors in a range of programs directed to personal recovery. The Partial Hospitalization Program (PHP) is a 12-week day treatment program for individuals with a serious and persistent mental illness that provides coordinated, intensive and interprofessional treatment that is skills based and meets the recovery needs of each patient. PHP is unique as it offers diverse services to aid in a patient’s recovery. In addition to its group therapy, coaching and psychoeducation, the program www.hospitalnews.com

NEWS offers leisure, recreation, music and art groups that prove to be an effective tool in fostering positive mental health, helping patients explore themselves and better communicate in a non-traditional form. The last 100 years have seen a tremendous amount of change in the way professionals have viewed and administered clinical and client-centred care. There is a stronger focus on the mental health and addictions system, partnerships and collaboration as well as advocacy, research, education and anti-stigma. Another notable step Ontario Shores has taken to advance its efforts for people living with mental illness is its recent collaboration with the four specialty mental health hospitals in Ontario, to celebrate the positive impact of its new provincial structured psychotherapy program. The collaboration embarks on a first-ever demonstration project to increase access to evidence-based structured psychotherapies. 2019 marks the third year of this project. By implementing the Cognitive-Behavioural Therapy (CBT) Unified Protocol, Ontario Shores was able to leverage existing models, ensure fidelity and create structures for standardization and clinical support to rapidly implement a high quality service to demonstrate clinical outcomes. Overall, patients are showing significant measurable changes in depression and anxiety symptoms, with some moving from moderate levels to sub-clinical or mild levels of symptoms. In addition there is a trend towards fewer and/ or less intense depressive and anxiety symptoms and improved general life satisfaction. The organization takes great pride in celebrating the current efforts as well as in its determination to create a better future for every person impacted by mental health issues. This milestone recognizes Ontario Shores’ past, celebrates recent achievements and shares a vision for the future of mental health care by advancing conversations about Ontario Shores and those impacted by mental illness. To celebrate the anniversary and recognize the exemplary care the organization provides, Ontario Shores selected six Ambassadors of Hope to help ignite conversations about mental health in the community.

Ontario Shores is proud to recognize Jordon Beenen, Ian Hakes, Kristie Jennings, Candice McAlister, Barbara Murray and Lori Lane-Murphy who have assisted with events, initiatives and campaigns associated with the 100 year anniversary of Ontario Shores. The six ambassadors have been an integral part of these initiatives and are helping spread the message about Ontario Shores and raise awareness of mental illness leading up to the anniversary. Through their lived experiences, advocacy work, volunteering and diverse career paths, each of them are determined to make a difference in the lives of people living with mental illness and are pushing to continue to remove the stigma associated with it. “I feel so honoured to be an ambassador and take part in the events for an organization that does such great things for people living with mental illness,” notes Beenen. “Being an Ambassador is especially important to me because it allows me to take a participatory role in stigma reduction and raise awareness toward mental illness. Taking part in the celebrations and projects leading up to the anniversary helps to validate me as a mental health advocate.” Some of the events leading up to the milestone included a Century of Care Speaker Series, featuring stories and topics that celebrate recovery, embrace the history and imagine the future leading up to this anniversary as well as a partnership with the Robert McLaughlin Gallery. The collaboration engaged the community with a focus on art through the lens of mental illness. In addition, the organization continued its celebrations with a juried art show during July and August where it welcomed works of art that connect with mental illness, mental health, recovery and its history of providing care. Through the various initiatives in celebration of the milestone, the organization is continuing its mission to normalize conversations surrounding mental illness. Ontario Shores has seen a great change in the mental health landscape, over the last century. However, the commitment and passion each and every person in the hospital has towards helping people living with mental illness H will always remain constant. ■

Melissa Quinlan is the communications coordinator at Ontario Shores for Mental Health Sciences. www.hospitalnews.com

Depression is the single largest predictor of

substance use during pregnancy By Crystal Mackay t is well known that tobacco, alcohol, and cannabis use during pregnancy are associated with poor birth outcomes, yet many women continue to use these substances during pregnancy. Researchers at Western University and its affiliate Brescia University College have now shown that depression is the single largest driver of substance use during pregnancy, highlighting the need for greater supports for the mental health of pregnant mothers. The research team analyzed health and geographical data gathered through Lawson Health Research Institute from more than 25,000 pregnant women in Southwestern Ontario. “Pregnant women who were depressed were 2.6 times more likely to use cannabis and twice as likely to smoke cigarettes and use alcohol while pregnant,” says Jamie Seabrook, PhD, and Associate Professor at Brescia and Western’s Schulich School of Medicine & Dentistry, and Scientist at Children’s Health Research Institute, a Lawson program. “We don’t know when the substance use first began but we do know that it was continuing during pregnancy and that is a big risk factor for poor maternal and infant health outcomes.” The study, published in the Journal of Neonatal-Perinatal Medicine, is the first Canadian study with a sample size this large to show that depression during pregnancy is the primary risk factor for cannabis, tobacco and alcohol use, and is more important than education, income, or age.

“This really highlights the importance of programming for mental health, including mental health promotion strategies, psychotherapy and safe and proper medication for mental health during pregnancy,” says Rachel Brown, an MSc candidate and first author on the paper. “The research shows that there is an effect later on in life as well with infants that are born preterm or low birth weight. To intervene or advocate for mental health programs for the mom, the idea is that it sets up the health of the infants later on in life.” The research team points out that this research is especially important in Canada with the recent legalization of recreational cannabis. “Let’s help women with their mental health to improve their overall health and in doing so, improve the health of their baby,” says H Seabrook. ■

Crystal Mackay works at Western University’s Schulich School of Medicine & Dentistry. OCTOBER 2019 HOSPITAL NEWS 43

SAFE MEDICATION

Medication incidents

associated with patients undergoing dialysis By Kendra Carroll, Grant Fuller, Alan Ho Lun Li, and Certina Ho he kidneys are one of the main organs responsible for eliminating medications from the body. If dosing adjustments are not made based on a patient’s kidney function, increased exposure to the medication may put the patient at risk of side effects, serious harm, or even death. Dialysis is a life-saving way to remove toxins from the blood of people with severely reduced renal function. There are several modalities of dialysis, each with its set of complexities. As patients who undergo dialysis require an increasing number of medications, situations of inappropriate medication use may become more frequent. The likelihood of medication incidents is particularly high in community pharmacies, where there is often limited access to patient medical records and lab values. However, pharmacists are uniquely positioned to intervene and resolve scheduling and dosing errors concerning dialysis patients. The objective of this article is to present results from a multi-incident analysis of medication incidents reported in community pharmacies involving patients undergoing dialysis.

METHODS

A total of 134 incident reports were extracted from the ISMP Canada Community Pharmacy Incident Reporting (CPhIR) program www. cphir.ca from June 2014 to May 2019 and met the inclusion criteria for the analysis. A collection of broad search terms such as “GFR”, “Dialysis”, “Kidney” and “Renal” were used to capture incidents involving patients with renal impairment. Thirty-eight incidents were excluded as they did not involve the target patient population. Two

Incident Examples

Contributing Factors

Metoprolol was supposed to be placed in blister packaging except for dialysis days. Medication was placed in the wrong slot in compliance packaging. Pharmacist noticed mistake when checking packages and mistake was corrected.

Ambiguity of prescriptions or lack of indicated changes in therapy

Prescription was misinterpreted: Keflex 500 mg po daily (to give after dialysis on Tuesday / Thursday / Saturday) for 2 weeks. Medication was filled as 6 tablets for the 3 days of the week indicated for 2 weeks. Patient phoned back to explain that the medication is supposed to be taken every day for 14 days after dialysis on the indicated days so as not to get dialyzed and removed from the patient.

Lack of independent double checkst

Commentary

Dialysis introduces complexities in medication therapy management in patients. This includes medication errors due to scheduling complexities.

Table 1 – Medication Incidents Associated with Patients Undergoing Dialysis independent analysts conducted a multi-incident analysis of the data identifying common themes, subthemes, contributing factors, and recommendations to improve patient safety. The results presented in this article focus on a subset of the reports pertaining to dialysis. Of note, 86 of the 134 incidents analyzed were classified by reporters as “Near Misses” that were intercepted before reaching the patient. Therefore, many of the incident examples and contributing factors or interventions should be interpreted as demonstrating best practices by pharmacy professionals, rather than errors that should be avoided.

RESULTS

Incident examples, potential contributing factors, as well as recommendations to improve the care of patients undergoing dialysis are provided in.

RECOMMENDATIONS

Access to patient’s medical records, lab values, and test results by healthcare professionals would help improve the quality of care provided to patients undergoing dialysis. This includes pharmacists who would require access to indicators of patient’s renal function in order to evaluate the appropriateness of medication therapy and to recommend suitable alternatives if applicable.

FOR PHARMACISTS

• Consider implementing an independent double check system for medications prescribed to patients receiving dialysis. • Ask patients about changes to their medical/medication history at every visit and document changes prominently in the patient profile. • If there are concerns that the dose or medication is not appropriate for a patient on dialysis, contact the prescriber

to verify the degree of renal impairment. • Utilize the pharmacist’s expanded scope of practice to adapt prescriptions as appropriate for patients with renal impairment.

FOR PRESCRIBERS

• Include relevant lab values (e.g. CrCl, SCr, INR, A1C, etc.) directly on prescriptions to allow pharmacists to independently assess appropriateness of therapy • Include rationale supporting changes in therapy on prescriptions (e.g. patient on dialysis or renal function declining, etc.)

CONCLUSION

Patients on dialysis are prone to medication incidents. They are often cared for by multiple providers, and collaboration is needed within the circle of care to prevent errors and H provide the best possible care. ■

Kendra Carroll is a PharmD Student at the Leslie Dan Faculty of Pharmacy, University of Toronto; Grant Fuller is a PharmD Student at the School of Pharmacy, University of Waterloo; Alan Ho Lun Li is a BScPhm Student at the School of Pharmacy, The Chinese University of Hong Kong; and Certina Ho is a Project Lead at the Institute for Safe Medication Practices Canada (ISMP Canada). 44 HOSPITAL NEWS OCTOBER 2019

www.hospitalnews.com

NEWS

New treatment for bipolar depression could have fewer side effects By Vivian Sum eople who come to us have symptoms so severe that they are not able to enjoy their life, work or relationships,” says Vancouver Coastal Health Research Institute clinician-scientist Dr. Fidel Vila-Rodriguez. Vila-Rodriguez is leading the Vancouver arm of a clinical trial investigating magnetic seizure therapy (MST) to treat bipolar depression. The study – which is also recruiting patients in Toronto and London, Ontario – will compare the effectiveness and side effects of MST with the current electroconvulsive therapy (ECT) approach. Results from the first randomized, double-blind study of its kind could lead to changes in how very severe cases of bipolar depression are treated. “When we see patients, they have invariably already tried other treatments for their bipolar depression, such as psychotherapy and medications,” says Vila-Rodriguez.

“

ECT, which has been used since 1938, is shown to be one of the most effective therapies to put treatment-resistant depression into remission, with a reported 65 to 75 per cent success rate. However, a 2003 study published in the British Medical Journal found that at least one third of patients who underwent ECT reported persistent memory loss, which can deter some patients from pursuing this treatment.

IDENTIFYING THE BEST THERAPY FOR TREATMENT-RESISTANT BIPOLAR DEPRESSION

While both ECT and MST induce minor seizures in the brain, patients are placed under general anesthesia to prevent body convulsions. Patients’ heart rate, level of blood oxygenation and blood pressure are all monitored during treatment. However, unlike ECT, MST uses magnetic currents, not direct electricity.

Dr. Vila-Rodriguez and the MST machine. includes psychotherapy and medication. And given its potential fewer side effects, MST could offer patients concerned about potential memory loss greater peace of mind.

“For some patients, this type of therapy is like flipping a switch,” says Vila-Rodriguez. “After a few sessions, their enjoyment of life, as well H as their productivity, returns.” ■

Partnership Conference

ECT, WHICH HAS BEEN USED SINCE 1938, IS SHOWN TO BE ONE OF THE MOST EFFECTIVE THERAPIES TO PUT TREATMENT-RESISTANT DEPRESSION INTO REMISSION, WITH A REPORTED 65 TO 75 PER CENT SUCCESS RATE. Most patients are around 45 years of age and approximately 60 per cent are women. Many may be contemplating suicide or harming themselves in other ways, placing them in a life-threatening situation. Around one per cent of Canadians over 14 years of age will have symptoms of bipolar. In addition, around 700,000 Canadians were affected by treatment-resistant depression – when a patient does not respond to at least two antidepressants – in 2014.

The seizures release neurotransmitters, such as adrenaline, dopamine and GABA – an inhibitory transmitter that stops the seizure. This process triggers neurogenesis, which produces new neurons in the brain. “If this research shows that MST and ECT are similarly effective, but MST has fewer side effects, MST may quickly replace ECT as the preferred treatment.” ECT and MST are part of a treatment mix for bipolar depression that

Vivian Sum works in communications at Vancouver Coastal Health Research Institute. www.hospitalnews.com

OCTOBER 2019 HOSPITAL NEWS 45

LONG-TERM CARE NEWS

Bedlam in BC’s continuing care sector By Michael Kary n early April of this year a heart breaking story appeared in the media highlighting a senior from Vernon, BC who was waiting over three months and in desperate need of admission into long-term care. A follow-up story that same month also showcased that the Interior Health region has the longest waitlist for long-term care among the province’s five health authorities. While unfortunate, these stories are likely to become more prevalent in the future as BC, like the rest of Canada, fac-

BRITISH COLUMBIA IS ALREADY SHORT 3,000 LONG-TERM CARE BEDS AND REQUIRES AN ADDITIONAL 31,000 BY 2035. es a rapidly aging population. In BC, for example, it is predicted the percentage of seniors will almost double to account for about a quarter of the population within the next twenty years. With a growing and rapidly aging population, the continuing care

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sector will require new resources to meet the needs of seniors. Unfortunately, however, BC is already facing a shortage of long-term care beds, which is affecting people and families who are impacted by delays to care including transitions from hospital or home health care. BC Care Providers Association (BCCPA) in a recently released report entitled Bedlam in BC’s Continuing Care Sector: Projecting Future Long Term Care Bed Needs highlights many of these access challenges. As outlined in the BCCPA report and data provided by the Conference Board of Canada, BC is already short over 3,000 long-term care beds. The same data also projects that BC requires an additional 31,000 (30,900) new long-term care beds by 2035 to meet future demand due to a rapidly aging population The BC Ministry of Health has also outlined that the growth in demand for health care for frail elderly living in long-term care is projected to increase by 120 per cent by 2036. More recent data also highlights that the number of frail elderly living annually in residential or long-term care in BC is expected to almost triple (from 38,000 to over 106,000) by 2042. As such without significant increases to the number of long-term care beds it is likely that media stories such as the one of the Vernon senior seeking admission to a long-term care home will only become more common.

According to the most recent BC data, as of March 2018, there were about 1400 (1,379) persons waiting for admission into long-term care – a seven per cent increase over the previous year. About 75 per cent of those waiting for admission into long-term care (1039 of 1379) were those living in the community compared to the remainder who were waiting in hospital. The latter group or alternate level of care (ALC) patients highlights not only the shortage of long-term care beds but also the lack of other resources or supports in the community including home health care. Overall, and as outlined in the BCCPA paper, the access situation is only going to worsen unless there are substantial increases in the number of new beds. In BC, request for proposals (RFPs) for new long-term care beds are generally posted on the BC Bid website, yet over the past six months only one RFP for new long-term care beds has been awarded. While new long-term care beds are critical, it is important, however, to recognize that some of this demand can also be potentially offset through other areas in the continuing care sector particularly home health care and assisted living. While these areas and other approaches might mitigate some of the demand, no single intervention, however, will offset the demand for long-term care beds as well as uphold individual preferences to remain in community as long and as independently as possible. To meet future demand, the role of the private or non-government sector (including for-profit and non-profit) will also be critical, particularly from a financial perspective. www.hospitalnews.com

LONG-TERM CARE NEWS

THE GROWTH IN DEMAND FOR HEALTH CARE FOR FRAIL ELDERLY LIVING IN LONG-TERM CARE IS PROJECTED TO INCREASE BY 120 PER CENT BY 2036. The BC government recently announced that over the next two years, several health authorities (Fraser, Island and Vancouver Coastal) will be taking over the delivery of all funded home support services. This is likely to increase the costs of delivery of such care by as much as 30 per cent and as such BCCPA has also asked the BC Auditor General to review the Ministry of Health’s decision to cancel contracts with six non-government home care providers and expropriate over 4,000 staff into government-operated health authorities. Similar to the anticipated impacts of expropriating home support services, BCCPA believes that the costs to taxpayers would be considerably higher if the government were to move funded long-term care beds from the private sector to the health authorities. Also, the construction and operation of new long-term care beds by the government would add major new costs to the taxpayer. While a significant number of new long-term care beds are required to meet demand, this also does not account for existing beds that may be in care homes in BC that are outdated and require renovation or in some cases rebuilding. As outlined in the BCCPA paper, about 40 per cent of longterm care homes in Canada require significant renovations or to be rebuilt, according to one national survey. Along with new bed demand and ensuring current care homes are up to date, some of the other challenges explored in the paper include rising levels of acuity or complexity as seniors

are entering long-term care later in life. With higher levels of acuity and meeting the demand for new beds, it will require substantial more health professionals particularly health care assistants. BCCPA estimates that based on the Conference Board projection in which BC requires about 31,000 (30,900) new long-term care beds by 2035, that to meet this demand it would require about 19,000 new care providers including almost 13,000 health care aides, 4000 nurses and 2000 allied health professionals. As such based on various data sources as well as review of literature, BCCPA in its latest policy paper Bedlam in BC’s Continuing Care Sector has put forward twelve practical recommendations to improve access to seniors’ care and increase overall capacity in the long-term care sector. If fully implemented, the recommendations outlined in this report would be significant. For example, based on the Conference Board data, the total estimated cost of constructing and operating required for new long-term care beds to 2035 in BC alone would be close to $30 billion. Given the importance of seniors particularly with an aging population we believe that such investments, however, are worthwhile. Without concrete action, wait times and wait lists for long-term care will only continue to grow as seniors are denied necessary access to the most appropriate care setting and ensuring quality of life in their remaining years. To view the reccomendations visit H www.bccare.ca ■

Michael Kary is the Director of Policy & Research, BC Care Providers Association. www.hospitalnews.com

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LONG-TERM CARE NEWS

Managing food-related allergies and intolerances in LTC By Dale Mayerson and Karen Thompson ood Hypersensitivity is an adverse reaction to food and can occur as a result of food allergy (allergic food hypersensitivity), food intolerance (non-allergic food hypersensitivity) or chemical sensitivity. There has been a dramatic rise in the incidence of food hypersensitivity in many industrialized countries over the past 20 years. Food-induced anaphylaxis remains a leading cause for emergency medical treatment and has become a major health concern in many countries. When residents move into long term care homes, they are asked about their food allergies along with their food likes and dislikes. Unfortunately, it is difficult to prove or disprove that a resident has a given food

allergy without either medical testing or developing an elimination diet. It is important to address and manage any reported allergies and intolerances even though many times a stated allergy may not be a true allergy, but simply an aversion or dislike.

FOOD ALLERGIES

A true food allergy results in a response of the immune system, usually to the protein of the food, which can range from a mild to severe reaction. Mild reactions can affect the eyes, skin, lungs, such as a rash or sneezing, but can also be more problematic, such as hives or vomiting. The most severe reaction is anaphylaxis, which can include extreme drop in blood pressure that affects the organ systems, swelling of the airway and death.

The immune system works by protecting the body and removing harmful elements, such as bacteria and other foreign particles. In an allergic reaction, this particle is called an antigen. The body mistakenly identifies a harmless food substance as a harmful antigen and produces antibodies to attack it, causing an array of allergic reactions. Common allergens include milk, eggs, shellfish, nuts, wheat, peanuts, soybeans and chocolate. More recently, mustard has been added to the list of possible food allergies.

FOOD INTOLERANCES/ SENSITIVITIES

A food intolerance is different than a true food allergy. A food intolerance causes a reaction that does not trigger the immune system. Most symptoms

affect the digestive system, with symptoms of nausea, vomiting, abdominal pain and diarrhea. Unlike a food allergy, food intolerance requires a larger portion of an offending food and a longer time (hours or days) to elicit an adverse reaction. The most common food intolerance is to lactose, the sugar found in milk. In this case, the body does not produce enough of the enzyme lactase, which is needed to split the lactose molecule so it can be absorbed from the digestive tract into the blood. If the enzyme is not available, the lactose cannot be split and the build-up of lactose causes abdominal pain and diarrhea. Chemical sensitivity is an adverse reaction to a chemical that either occurs naturally in or is added to a food. Such chemicals include caffeine in

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LONG-TERM CARE NEWS

tea, coffee or chocolate, tyramine in aged cheese, monosodium glutamate (MSG), sulphites, and other additives in processed foods. These can cause heart palpitations and/or headache. Reactions to food sensitivities, as well as food allergies, will vary with the individual.

NUTRITION CARE

Determining residents’ food allergies, intolerances and nutritional or chemical sensitivities is the first step in managing them. Nutrition care staff ensure they are noted in the resident’s medical chart and on the diet list and high risk intolerances are noted as such and documented accordingly. It is prudent to obtain information from previous caregivers/homes and to create a communication plan for all staff. Strategies should be developed based on the inherent risk associated with the allergy or intolerance; this can include

DETERMINING RESIDENTS’ FOOD ALLERGIES, INTOLERANCES AND NUTRITIONAL OR CHEMICAL SENSITIVITIES IS THE FIRST STEP IN MANAGING THEM.

the use of identification/signage for the resident to alert staff, assessing seating assignments in the dining room, individualizing of snacks and meals. Home and Nursing Administrators should be made aware of high risk situations and the strategies that have been implemented to manage the risk. For a true allergy, only a trace of a food can cause a reaction. It is important to practice good hygiene to avoid the risk of cross-contamination while food is being prepared. It is also essential to read labels of purchased foods to be sure that the allergen is not in

the product. Some residents may have negative reactions to food flavourings or food colours that are widely used. Sauces, salad dressings and other bottled products need to be checked if these are concerns. Residents who are allergic to very common foods that are widely used, such as milk, wheat or eggs, may need to have an individualized menu developed for meal and snacks. Any allergy that can affect a whole food group needs to be closely monitored to avoid a vitamin or mineral deficiency. Substitutes can be used that provide

similar nutrition, for example, fortified soya milk is a reasonable substitute for cow’s milk, since it has comparable protein. Almond milk and rice milk do not contain equivalent protein and therefore would not be the best substitutes. Rice cakes or corn tortillas can be used in place of bread for wheat allergies. All employees are trained in management of allergies and keep watch for possible hazardous foods in order to keep residents safe. In case of an allergic reaction, there would be an investigation to track what the resident ate. Since residents may have access to a tuck shop, or may have a treat that a family member (or another resident’s family member) brought into the home, there are several aspects that this investigation would need to take. The goal is to keep residents safe and enjoying their food, both for their physical well-being and for their H quality of life. ■

Dale Mayerson, BSc, RD, CDE, and Karen Thompson, BA Sc, RD are Registered Dietitians with extensive experience in Long-term care. They are coauthors 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.

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OCTOBER 2019 HOSPITAL NEWS 49

LONG-TERM CARE NEWS

App for dementia caregivers launches By Rebecca Ihilchik p to 90 per cent of people with dementia will experience behavioural and psychological symptoms that will be disturbing or challenging to their caregivers – such as physical or verbal aggression, wandering, agitation, or resistance to support, in addition to others. These symptoms can cause stress for caregivers that is itself associated with early or frequent admission to hospital and long-term care homes for the person with dementia. An app that supports caregivers of people with dementia and helps them better care for their loved ones and clients was launched to market earlier this year, with CABHI support. “Caregivers don’t necessarily have the background to manage dementia,” says Einat Danieli, project manager at Baycrest. “They really need some access to quick information and tools that can support them in coping with these challenges in the home environment.” Danieli is the brain behind the Dementia Talk App, an innovation supported in part by the Centre for Aging + Brain Health Innovation (CABHI), powered by Baycrest. An occupational therapist by background, Danieli was inspired by her own knowledge and experience working with caregivers of people with dementia to create a technological solution that addressed their concerns. The Dementia Talk App works as a tool for caregivers to track behaviours and develop a care plan to manage their loved ones’ symptoms. Its six features – a behaviour tracker, behaviour care plan, ‘my team’ sharing feature, medication list, calendar, and ‘caregiver corner’ – act as a cohesive one-stop shop for a caregiver’s needs. Karim Munjee is a Toronto-based working professional who tested the app while it was in development. He is the primary caregiver for his 74-yearold mother, who was diagnosed with

Einat Danieli, project manager at Baycrest with the Dementia Talk app.

THE DEMENTIA TALK APP WORKS AS A TOOL FOR CAREGIVERS TO TRACK BEHAVIOURS AND DEVELOP A CARE PLAN TO MANAGE THEIR LOVED ONES’ SYMPTOMS. ITS SIX FEATURES – A BEHAVIOUR TRACKER, BEHAVIOUR CARE PLAN, ‘MY TEAM’ SHARING FEATURE, MEDICATION LIST, CALENDAR, AND ‘CAREGIVER CORNER’ – ACT AS A COHESIVE ONE-STOP SHOP FOR A CAREGIVER’S NEEDS. Alzheimer’s eight years ago. Karim, who works full time and is married with two young children, takes responsibility for all of his mother’s needs, including medical, financial, and social. With the app, Karim says, many caregiving duties will be simplified,

organized, and digitized. He’ll be able to keep a record of his mother’s behaviours, which will help him better understand and anticipate triggers. He’ll be able to accurately answer medical specialists’ questions about behaviour patterns without relying

on paper records or his own memory. He’ll also be able to easily refer a family member or personal support worker to medications or special needs his mother needs to take while he’s at work or away. Karim values the sense of emotional support the app gives him, especially the ‘caregiver corner’ feature which has useful self-care tips and resources. “Quite often family caregivers feel isolated. I know I have,” he says. “Having this app gives me somewhere to go for help in a timely way.” The Dementia Talk App was one of the first-ever projects funded by CABHI’s Spark Program, which supports the development and testing of promising early-stage innovations in seniors’ care by point of care staff. The app was developed at Sinai Health System’s Cyril & Dorothy, Joel & Jill Reitman Centre for Alzheimer’s Support and Training, where Danieli was a psychogeriatric resource consultant. CABHI funding allowed Danieli and her team to modify and expand some of the app’s back-end programming, as well as conduct beta testing of the app with a group of caregivers to gain valuable feedback about how to make it more user-friendly. The collaboration also gave Danieli access to CABHI’s acceleration services, which provide support to innovators in areas like business development in order to help speed up the commercialization or wide-scale adoption of their solution. The app is now available to be used anywhere in the world by caregivers like Karim. “My mother took care of my sister and I for so many years. Now it’s our turn to take care of her,” Karim says. He’s hopeful the app will help him do just that. Download the Dementia Talk App at www.dementiacarers.ca. Learn more H about CABHI at www.cabhicom. ■

Rebecca Ihilchik is a senior marketing and communications specialist at the Centre for Aging + Brain Health Innovation. 50 HOSPITAL NEWS OCTOBER 2019

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NEWS

Team approach to wound care leads to ‘fabulous’ experience By Caitlin Renneson or many people, a cracked callus is nothing more than a nuisance. But as a person with diabetes, Debora LePage knew that the one she saw on her left foot could be cause for concern. Debora decided to go to the Emergency Department at the Cornwall Community Hospital. An infection developed, and Debora was transferred to The Ottawa Hospital. The infection become so advanced that doctors had to amputate two of Debora’s toes. After the amputation, Chris Murphy Ph.D. and a nurse specialist at The Ottawa Hospital’s Limb Preservation Clinic (LPC) visited Debora to talk about how they might be able to speed up the healing process. Murphy works closely with other care providers at The Ottawa Hospital and in the surrounding community to care for nearly 1,500 patients per year who have conditions affecting the blood flow to their leg or foot. The LPC is a leader in Canada. It began several years ago as a pilot project that informally brought together care providers from The Ottawa Hospital with expertise in lower-body wounds. It has since expanded to include experts in vascular surgery, plastic surgery, infection prevention and control, orthopedics, chiropody and more. The model of care means that patients can access the experts they need without long delays. One of those vascular surgeons is Dr. Sudhir Nagpal. He sees great benefits to how the LPC is designed. “We’re all so close together, and we can’t underestimate how important that is,” he says. “It really improves patient care.” That team approach resonated with Debora. It wasn’t long before she started to notice how the teamwork among the experts at the LPC helped her foot get better, faster.

Christine Murphy, Ph.D. and Dr. Sudhir Nagpal are two of the dozens of health-care professionals who provide connected care to patients at the Limb Prevention Clinic. “The clinic was connected perfectly,” Debora recalled. “It was great. Anybody that dealt with me knew what was going on.” The fact that everyone in Debora’s care team was working so closely together had practical advantages, too. As a resident of Cornwall, Debora appreciated that her LPC appointments were scheduled for the same day. It saved her from having to make several trips to Ottawa in a week. Technology such as videoconferencing and digital graphs also help care teams keep track of a patient’s progress. “The graph lets us see if things are plateauing, or getting worse, and in

that case, I can go across the hall and speak to a vascular surgeon about it, and it’s acted on immediately,“ explained Murphy. As the wound healed, Debora continued receiving care from nurses in her community who themselves got support and guidance from the LPC. “The LPC is not just about patient care, although that is the primary focus,” says Dr. Nagpal. “We also educate community and primary nurses, publish papers and set up courses for physicians. The result is world-class wound management, vascular management and research.” For Murphy, the care lasts for as long as the patient needs it.

“I tell each patient that their care comes with a lifetime warranty,” Murphy explained. “Once the wound closes, if they have a small issue with it, we can respond to it quickly before it becomes a bigger issue.” Debora has since had to go back to the LPC for an issue in her other leg, but she did so with confidence. “It was fabulous care,” says Debora. “I felt that any concerns that I had were being taken seriously. They answered all of my questions, and I knew that I could call them at any time. Even though I was so far away form home, I felt like I was in the right place. I had no worries H at all.” ■

Caitlin Renneson is the Publications Officer at The Ottawa Hospital. 52 HOSPITAL NEWS OCTOBER 2019

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NEWS

Former addict finally likes what he sees in the mirror By Donna Danyluk hen he opened his eyes in the morning he had only drug use, pain and misery waiting for him. “I’ve struggled with addictions for more than 30 years, but the last two years were really bad. I used every penny I had to buy drugs. I would lie, cheat and steal – do anything – to get drugs,” said the 54-year-old Barrie, Ontario, resident. The addiction started as a way to numb the pain from a back injury he experienced as a plumber. It quickly became a way to block out the world. Having used Royal Victoria Regional Health Centre’s (RVH) Addictions Services in the past, Ron once again sought help knowing his current path was leading him straight to an early grave. That’s when he walked through the doors of the Barrie location (70 Wellington Street, West) of the North Simcoe Muskoka Regional Rapid Access Addiction Medicine (RAAM) service – a walk-in clinic designed to provide immediate help for people struggling with addictions. “I can tell you, if they didn’t see me right away I would have stepped right back into active addiction – back to drinking heavily, using cocaine, crack and opioids. Back to doing anything I could to build a wall between me and the world. I hated the world.” The RAAM Service is open Monday to Friday (8:30 a.m. to 4:30 p.m.) and includes walk-in clinics in Barrie, Orillia and Midland. The service was opened in response to the region’s growing opioid crisis. “The battle in the opioid crisis is not in RVH’s Emergency department, but out in the community,” says Dr. Chris Martin, an RVH Emergency physician and medical director of the Intensive Care Unit (ICU). Continued on page 55

The Stepped Care Model supports patients across Osler’s three sites. Patients can either attend group or one-on-one sessions based on their needs.

New options for those living with

mood and anxiety disorders By Donna Harris or people living with mood and anxiety disorders, timely access to the right clinical supports can make all the difference in the world to quality of life. It’s that thinking that prompted William Osler Health System (Osler) to launch a novel approach to service delivery that is dramatically improving wait times for services – all without any changes to staffing, space or resources. “When people are on waiting lists, their condition can continue to deteriorate,” says Carol McCafferty, Clinical Services Manager, William Osler Health System. “Our Stepped Care Model for Mood and Anxiety Disorders provides people with increased options for care that offer the best chance of positive outcomes.” Osler has one of the largest mental health and addiction programs in the province. Of the 75,000+ people it sees each year, close to 70 per cent are seeking help for mood and anxiety disorders. To help ensure easier access to services, Osler took a proven national program used in

the United Kingdom, and successfully scaled it to their community to help address the more than 1,400 referrals it receives each month for services. Since introducing the Stepped Care Model in January 2019, Osler has almost doubled access to its outpatient mental health programs and intervention services, and significantly reduced wait times to see a psychiatrist or psychotherapist. “Our goal was to increase access to services, reduce wait times, decrease visits to the emergency department, and increase patient and primary care satisfaction,” says Faiza Khalid-Khan, Osler’s Director of Mental Health and Addictions. “So far, the Stepped Care approach is living up to its reputation on all fronts, reducing the time to see a psychiatrist from 12 months to four, and access to group services from six months to 1-4 weeks.”

MATCHING PATIENTS TO SERVICES BASED ON LEVEL OF NEED

The model’s four-step approach matches patient level of need to

level of service, reserving the most intense, resource-rich services for patients with the most complex needs. Prior to implementing the model, mental health services tended to focus on individual therapy and longer-term support, leading to long waits, particularly for psychiatry services. By reconfiguring existing resources and staffing, Osler was able to increase the number of low intensity services available to patients and expand the number of therapeutic groups from 21 to 53. A new centralized intake process ensures patients are referred to the most appropriate service to meet their needs. “We don’t want to burden patients with more services than they need,” says Carol. “Through Stepped Care, patients can enter the model at the level of service that will best meet their needs. For some, the services in one level might be all they need prior to being discharged from the program, while others may need to move through two or more levels, up or down, depending on how well they are doing.” Continued on page 54

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OCTOBER 2019 HOSPITAL NEWS 53

NEWS

A fine dining experience for patients

Continued from page 53

By Taylor Grant ating in the hospital isn’t usually your first choice. When it comes to mealtime, hospital cuisine has traditionally gotten a bad rap. But a hospital menu does more than curb hunger – it’s an essential part of the treatment and care of patients. Three times a day, 365 days a year, Patient Food Services staff at the North Bay Regional Health Centre (NBRHC) focus on serving quality meals that are planned to meet patients’ needs. Providing the same comforts of home cooking can be a challenge, as many hospitalized patients are required to adhere to a strict diet – often with salt restrictions. “In hospital, we can’t just provide anything. We need to know who is allowed to eat what,” notes Natalie Lepine, Manager of Patient Food Services at NBRHC. “Food served to patients goes through a vetting process together with physicians and dieticians to ensure meals meet various dietary requirements and therapeutic needs.” Sandy Sikora, a Peer Specialist with the NBRHC explains outside of the hospital setting, many people do not eat meals alone, in silence or watching television. “Mealtime is a social activity and a chance to bond with family and friends,” says Sikora. “Food is also connected with selfworth and role identity. Cooking for others gives people a sense of purpose and an opportunity to give back.” For long-stay patients, the opportunity to prepare food or go out to eat is limited, so the Health Centre created a cooking group to bring a small touch of normalcy to the patients’ daily routine. “During the holidays, we noticed some patients couldn’t go home. So last Christmas we decided to start a cooking group to make a homecooked meal,” says Sikora. “It gave patients a chance to develop basic skills while socializing in a group setting. The feedback was amazing, so we decided to continue meeting for special occasions such as during Mental Health Week.”

Over 20 NBRHC employees volunteered their time to greet and serve the invited guests. The group participated in meal planning and menu selection. Sikora said they were surprised most of the requests were for simple, everyday items. One of the biggest request was to have a sit-down dinner with salt and pepper shakers.

A SPECIAL NIGHT OUT, IN

The request sparked an idea: a formal event called Come Dine with Me for patients and their guests to sitdown for a plated meal with linens, menu cards, centrepieces, music, and of course salt and pepper shakers. Sikora fondly remembers her first fine-dining experience and it was something she wanted to share with patients. “Our patients have the opportunity to eat out, but it’s often fast-food restaurants and they do not have a lot of experience being served. And our senior patients have trouble leaving without the help of family or friends,” says Sikora. “We wanted to give them a special night out here at the Health Centre.” Bob and Christina Golding have been married for 50 years, and made Come Dine with Me into a date night. Bob, a retired pipefitter, is a patient at NBRHC. “I didn’t know what to expect when I accepted the invitation,” Christina says. “When I walked into the room I was astonished by the effort given to make it a dining experience. It was

good for Bob and me, because everything was taken care of and we were able to just relax. Bob and I sat there, held hands and talked.” An important part of the Come Dine with Me experience involved patients selecting the menu. On the wish list was potatoes. Come Dine with Me gave Patient Food Services staff an opportunity to be creative and work outside the strict perimeters of everyday requirements. “We were excited to get involved and be a part of the discussion,” Lepine said. “For us it was fun to try something new, such the roasted redskinned potatoes.” For the Goldings, it was a hit. “The potatoes had so much flavour. Bob thought he died and went to heaven,” laughs Christina. “Bob loved those potatoes.” When the 97 invitees arrived for dinner, they were escorted to their seats by staff dressed in black and white. The handmade centerpieces looked beautiful on the table where the sun captured all of the colours in the peacock feathers. Overhead music set the tone as staff from management and frontline interacted with guests and served their meals. “Every staff member that participated volunteered their time that evening, knowing that they would make a difference in the lives of many,” says Tanya Nixon, Vice President of Mental Health at H NBRHC. ■

Taylor Grant is a Communications Assistant at North Bay Regional Health Centre. 54 HOSPITAL NEWS OCTOBER 2019

Mood and anxiety disorders Step 1 is low intensity, offering self-management skills and an introduction to relaxation strategies. Step 2 focuses on cognitive behaviour therapy, teaching patients techniques for dealing with symptoms of anxiety and depression. Step 3 offers more intensive therapy for mood and anxiety disorders, while Step 4 delivers more 1:1 counselling. “The model’s flexibility means that treatments are more tailored to individual needs,” says Carol. “If a patient isn’t comfortable doing group therapy, they will initially receive 1:1 therapy with the ultimate goal of transitioning to a group.”

ADOPTING A CONSULTATIVE APPROACH TO PSYCHIATRIC CARE

Osler has also moved psychiatry referrals to a consultation/collaboration model with primary care providers. A psychiatrist may see a patient for one or more sessions, then refer the patient to the Stepped Care Model, with follow-up care upon discharge going back to the referring primary care physician rather than to the psychiatrist.

A NEW CENTRALIZED INTAKE PROCESS ENSURES PATIENTS ARE REFERRED TO THE MOST APPROPRIATE SERVICE. “Historically, primary care providers would refer a patient to a psychiatrist and that patient might be with that psychiatrist for the rest of their life,” notes Faiza. “But advances in medications and more sophisticated outpatient mental health services means primary care providers are better equipped to monitor the ongoing needs of their patients, leaving psychiatrists with more capacity to focus on those people with H the highest intensity needs.” ■ Donna Harris works in communication at William Osler Health System www.hospitalnews.com

NEWS

Addictions Continued from page 53 “People who use drugs are playing a deadly game of Russian Roulette because so many drugs – from cocaine to heroin – are being laced with synthetic fentanyl. Clinics like RAAM are helping people address their addictions, keeping them alive.” The RAAM Services have been open for just over a year and during that time more than 864 people, just like Ron, have walked through the doors ready to beat their addictions. In 2018 the Barrie, Orillia and Midland RAAM clinics saw a combined total of 3,874 visits for addiction-related concerns. “When you are in active addiction and you are ready to make that move to quit, having someone to talk to immediately is crucial,” says Ron.

Mandy Heacock, welcomes a client to the Barrie site of the North Simcoe Muskoka Regional Rapid Access Addiction Medicine (RAAM) service - a walk-in clinic designed to provide immediate help for people struggling with addictions. Since opening, a year ago, 864 clients have sought help at the three clinics in Barrie, Midland and Orillia. For him, that ‘someone’, was the dedicated addiction counsellors with the Barrie RAAM Program.

“We know that when people walk through our doors it takes a lot of courage. For many individuals this is

their last stop, their last place of hope. We recognize that immediate access is paramount to our clients’ success,” says Brian Irving, manager Addictions Services and North Simcoe Muskoka RAAM Services, RVH. “Our job is to provide a safe supportive environment, one that allows the person to feel respected and heard.” Today, thanks to RAAM, Ron is a different man. He’s clean, sober and the former plumber is now teaching technical courses to plumbing apprentices – a position he calls ‘his dream job’. “I’m so blown away about how much my life has changed in just a year,” says Ron. “For the first time when I look in the mirror I love the guy staring back. I tell people when you give up drugs you don’t just get your life back – you get a better H life!” ■

Donna Danyluk is with Royal Victoria Regional Health Centre’s (RVH) Corporate Communications department.

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OCTOBER 2019 HOSPITAL NEWS 55

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