hospital news 2016 july edition

INSIDEEthics .................................................... 7

From the CEO’s desk .........................12

Evidence Matters ...............................18

Nursing Pulse .....................................19

Long Term Care ..................................20

Careers ...............................................23

Testing new ways to screen for loss of sensation in diabetic patients

High-tech heart-valve heals seniors too weak for open-heart surgery

6 10

FOCUS IN THIS ISSUECARDIOVASCULAR CARE/RESPIROLOGY/DIABETESDevelopments in the prevention and treatment of vascular disease, including cardiac surgery,diagnostic and interventional procedures. Advances in treatment for various respiratory disorders, including asthma and allergies. Prevention, treatment and long-term management of diabetes and other endocrine disorders.JULY 2016 EDITION | VOLUME 29 | ISSUE 7

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Up to one third of medical care adds no value to patients

Story on page 14

When more isn’t better

062516_HN_EDIT.indd 1 2016-07-05 2:16 PM

HOSPITAL NEWS JULY 2016 www.hospitalnews.com

2 Focus CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH

he Sumac Creek Health Cen-tre will soon roll out a half-day health promotion pro-gram to help patients with

chronic obstructive pulmonary disease to breathe easier.

Chronic Obstructive Pulmonary Dis-ease (COPD) is a lung disease that in-cludes chronic bronchitis and emphy-sema, and develops over time. Symptoms include an ongoing cough that produces mucus, shortness of breath, wheezing and chest tightness.

Registered nurse Carolene Garcia is a COPD champion who “quickly recog-nized this specific population has exten-sive needs – especially following discharge from hospital.” Garcia noted the COPD patients she works with are mostly low in-come, live alone with no social support, and have multiple co-morbidities.

That’s why she is creating a program with a team-based approach: she will work with a pharmacist and dietitian, as well as other healthcare professionals, to assist with managing the disease and, most importantly, to improve patients’ quality of life.

Patients with COPD are fearful of becoming short of breath and often ar-rive in the Emergency Department with an exacerbation, or a sudden worsening of symptoms.

“I see patients with COPD struggle ev-ery day,” she says.

The dietitian will work with patients to prevent or reverse malnutrition by imple-menting strategies to minimize weight loss and improve the ability to eat. The pharmacist will help with medication rec-onciliation, treatment optimization and patient education.

Garcia, who will be the COPD re-source, and the Sumac Creek RN team

will manage patient cases, ensure pa-tients have a good understanding of the disease process, refer patients to other al-lied health professionals, and connect pa-tients to available community resources/services such as pulmonary rehabilitation and home care.

“Having a well-thought out collabora-tive plan of care can have a direct impact improving health outcomes and possibly decrease readmission to the hospital,” she says.

Jacqueline Chen, the clinical leader manager at Sumac Creek, says Garcia and the rest of the primary care team are well-positioned to provide tailored care to this patient population. “With good, co-ordinated care and patient engage-ment, we can help prevent unnecessary visits to the Emergency Department,” says Chen. nH

Melissa Di Costanzo works in communications at St. Michael’s Hospital in Toronto.

By Melissa Di Costanzo

T

Registered nurse Carolene Garcia is a COPD champion

Building up one group by tearing down another is never the right answer

n May 9, the Registered Nurses Association of On-tario (RNAO) published a position paper called ‘Mind

the Safety Gap: Reclaiming the Role of the RN’. This document and the ensu-ing campaign to promote it has been viewed by many in healthcare as an unapologetic attack on Ontario’s reg-istered practical nurses (RPNs) and, in particular, their work in the acute care sector, where they have provided ex-cellent care for many years.

Our association avoids engaging in intra-professional conflicts in the press. Given the contents and recommenda-tions of this document, however, there is no other alternative but to respond on behalf of the province’s 39,000 RPNs.

This document contains inconsis-tencies, contradictions and mislead-ing statements. It is based on ques-tionable assumptions and uses partial statistics to support its premise. And while purporting to put patients first, in reality, this document questions the decision-making abilities of Ontario’s nursing leaders, prioritizes turfism at the expense of collaboration and seeks to elevate RNs by tearing down their RPN colleagues (who are regulated by the same college as RNs, the College of Nurses of Ontario, and required to practice to the same standards).

RNAO uses the term ‘RN Replace-ment’ to imply a systematic campaign aimed at replacing RNs with RPNs. And while ‘RN Replacement’ makes for tantalizing headlines, this is an incredibly oversimplified label for the complex changes taking place in healthcare.

The document compares the growth rates of RN and RPN positions but re-fers to them as ‘shares’ of nursing, with no definition of what a ‘share’ is. If a ‘share’ refers to a nursing position, the comparison would be inaccurate, since RPNs have a much lower full-time employment rate than RNs. Compar-ing positions in this manner would be ‘apples to oranges’.

The document also promotes the idea of PSWs, RNs and NPs working to full scope of practice. Yet, when hos-pitals work to allow RPNs to work to their full scope of practice, they are ac-cused of engaging in ‘RN replacement’. Ontario needs more of all categories of nurses working to their full scope of practice to service its healthcare needs.

Among its recommendations, RNAO proposes that the MOHLTC develop a Health Human Resources

(HHR) plan to align healthcare needs with the various types of care provid-ers. They propose their document should be the building block for that process. While we agree that it’s time to develop such a plan, it needs to be built from the ground up with input from all nursing groups as equal and respected partners.

The document proposes that the Ministry issue a moratorium on nurs-ing skill mix changes until the comple-tion of the HHR plan. Yet, on the fol-lowing page, it proposes sweeping and immediate skill mix changes.

The document calls for the elimina-tion of RPNs from Ontario hospitals. It is true that the majority of hospital patients require care by an RN.

However, there are many patients in acute care (e.g. well moms, well babies and patients in continuing care, re-habilitation and less complex medical and surgical patients) for whom RPNs provide excellent care. In addition, 14 per cent of hospital patients today are classified as alternate level of care (ALC), or no longer requiring acute care, a patient population well within the appropriate practice of an RPN. RPNs absolutely have roles to play in acute care hospitals. For an outside group to suggest otherwise is offensive.

The document uses the term ‘di-ploma-prepared’ to refer to RPNs. RNAO also refers to RPNs as ‘less qualified personnel’. Their docu-ment fails to mention that both cat-egories of nurse have a wide range of educational backgrounds within their designations and there are fabulous nurses from both categories who are diploma-prepared. That is not to say that RPNs and RNs are the same – they are not. The point is that using RPNs’ education to attempt to dimin-ish their effectiveness as care providers is wrong. An Ontario RPN’s educa-tion is comprehensive, grueling and, as is the case with many other health providers, has evolved immensely over time, providing these nurses with the expertise to do their jobs in all sectors of healthcare.

Ontario is facing significant health-care transformation. All of us need to be invested in addressing this chal-lenge. However, holding back one group from practicing in the manner that they’ve been educated in order to advance another group is completely counter to that goal.

Building up one group by tearing down another is never the right an-swer. We’re stronger together. nH

O

Helping COPD patientsbreathe easier

Letter to the Editor

Re: Nursing Pulse Column June

Sincerely, Dianne Martin, Executive Director The Registered Practical Nurses Association of Ontario (RPNAO)

062516_HN_EDIT.indd 2 2016-07-05 2:16 PM

JULY 2016 HOSPITAL NEWSwww.hospitalnews.com

3 In Brief

Unnecessary hospitalizations due to chronic disease are reaching the tipping point of seriously harming this country’s healthcare system and do not meet the needs of patients and their families, ac-cording to a report by the Canadian Foundation for Healthcare Improvement (CFHI).

According to CFHI, diseases such as chronic obstructive pulmonary disease (COPD) are placing a growing strain on Canada’s healthcare system. Of all chronic diseases, COPD is the number one reason for hospitalizations in Cana-da, accounting for the largest number of return visits to emergency departments. COPD also generates the highest volume of hospital readmissions.

CFHI announced new results from a national initiative that shows hospital-izations due to COPD can be decreased by up to 80 per cent when healthcare is provided to patients and their families at home. This transformational approach not only improves quality of care, but would also avoid 68,500 emergency de-partment visits, 44,100 hospitalizations and 400,000 bed days – saving $688 million in hospital costs over the next five years.

A conservative estimate finds that about 800,000 Canadians live with COPD, yet people with advanced COPD are among the highest users of Canada’s hospital resources. One in four Canadi-ans over age 35 are expected to develop the disease in their lifetime, meaning the situation is forecast to worsen in coming years.

“We knew this was coming,” says CFHI Vice-President, Programs, Ste-phen Samis. “Rising rates of chronic disease are straining our healthcare re-sources and staying the course is not an option. Canada continues to operate a healthcare system designed in the 1960s

that focuses on expensive acute care rather than helping people manage their chronic diseases in the community.”

CFHI, in collaboration with Boehring-er Ingelheim (Canada) Ltd.,supported 19 hospitals from every Canadian prov-ince to provide more effective, efficient and coordinated care to patients living with advanced COPD and their families.

The program, known as the INSPIRED collaboration, has enrolled 885 patients across Canada. For 146 of those patients who had participated in the program for a three- month pe-riod, their hospitalizations decreased by 80 per cent.

Patients also reported greater self-confidence, improved symptom man-agement and a return to daily activities such as climbing stairs, exercising, trav-elling and returning to work.

An independent analysis carried out by RiskAnalytica concluded that further expanding the CFHI/BICL INSPIRED collaboration would benefit 14,000 Ca-nadians a year and save $688 million in hospital costs over the coming five years. For every $1 invested in the pro-gram, $21 in hospital-based costs could be prevented. nH

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Of all chronic diseases, COPD is the number one reason for hospitalizations in Canada

Wrong care in the wrong place

While the last three and a half decades have seen the number of new cancer cases nearly triple, survival from cancer has also steadily increased, according to a new re-port – Ontario Cancer Statistics 2016 – re-leased by Cancer Care Ontario.

In this first comprehensive look at the state of cancer in the province, Cancer Care Ontario has compiled data from the Ontario Cancer Registry to provide a clear picture of cancer, focusing on the inci-dence, mortality, survival and prevalence of the disease.

The number of new cancer cases in On-tario is increasing and can largely be attrib-uted to an aging population and population growth. At the same time, cancer survival for nearly all cancer types is improving and mortality rates are declining, particularly from breast, colorectal and lung cancers. The five-year relative survival for all can-cers combined in Ontario is 63 per cent, which is a significant increase from 48 per cent in the mid-1980s.

The report, which is a definitive source for cancer surveillance information for On-tario, will be published every two years. It is intended to support decision-makers, the public health community, healthcare providers, researchers and others in plan-ning and evaluating population-based cancer control efforts, including those related to cancer screening, prevention and treatment.

“This data emphasizes the importance of the work we’re doing with our partners to reduce the burden of cancer in the prov-ince,” says Dr. Prithwish De, Director, Sur-veillance and Cancer Registry, Cancer Care Ontario. “Moving forward, this report will serve as a resource for us and others to ref-erence when making informed decisions, taking action and measuring the impact of our work.”

Key Statistics: • Approximately 1 in 2 Ontarians will de-

velop cancer in their lifetime and approx-imately 1 in 4 Ontarians will die from it.

• Approximately 85,648 new cases of can-cer are expected to be diagnosed in On-tario in 2016, which is almost triple the number of cases that were diagnosed in 1981 (29,649 cases)

• There are now more people living in On-tario with a diagnosis of cancer than there were 20 years ago – an estimated 362,557 people as of January 1, 2013 (or about 2.7 per cent of the population). nH

There’s more than one app for that – whatever “that” is. In fact, as recently reported in Hospital News, there are about 165,000 health or wellness apps out there. However, only a very small percentage of those apps are actually created by health-care or science-based organizations.

“For primary care providers who’d like to complement the care they provide to their patients – especially patients with chronic conditions – the difficulty is know-ing which apps are evidence-based, user-friendly and secure,” says Dr. Ed Brown, CEO, Ontario Telemedicine Network (OTN).

“OTN can make an important contri-bution by acting as a reviewer for apps,” he says, “using our experience and work-ing with our partners to provide an assess-ment of how well apps fill the need they’re meant to serve.”

To help OTN develop its app review – dubbed Practical Apps – Dr. Brown enlist-ed the help of Dr. Payal Agarwal, an Inno-vation Fellow at Women’s College Hospital Institute for Health System Solutions and Virtual Care (WIHV), who has a self-con-fessed passion for healthcare innovations.

“The field of virtual healthcare is mov-ing quickly. We want to be able to do rapid but reliable assessments to identify the tools that will actually help improve pa-tient outcomes,” says Dr. Agarwal. “Apps and digital health tools should be engag-ing and very easy to use for patients, but they must also produce meaningful data for physicians.”

Along with OTN Chief Medical Officer Dr. Rob Williams, Dr. Brown, Dr. Agarwal and a team of researchers at WHIV are developing a review of apps that address persistent patient conditions.

Each monthly review will address one topic, for example headaches and mi-graine, insomnia, hypertension or pre-diabetes, reviewing three to five of the best available apps for clinical evidence of effectiveness, usability, reliability, ac-cessibility and privacy and security.

“These are fairly common long-term primary care issues often tied to things like diet, exercise, lifestyle and medica-tion compliance,” says Dr. Williams. “Useful apps can drive the focus of care back to the patient, helping them better understand the dynamics that influence their problems, and provide advice on ways to manage.”

Practical Apps – available to health-care providers, administrators and consumers – will be published online (www.PracticalApps.ca) beginning in September. nH

OTN creates app review partnership

New Ontario cases have tripled since 1981

Cancer:

Canada NL PEI NS NB QC ON MB SK AB BC NWT NU YT

1 1 1 1 1 1 1 1 1 1 1 1 1 1

87,975 1,777 554 2,989 3,161 25,285 27,749 2,929 3,795 9,149 10,341 99 95 82

7.6 8.6 8.7 9.3 8.9 8.3 6.4 9.4 7.4 8.2 7.6 6.5 3.5 6.9

Province TerritoryRank as Chronic Disease Most

Responsible for Inpatient hospitalization Number of inpatient

HospitalizationsAverage Length of Stay (Bed Days)

of Inpatient Hospitalizations

Source: Hospital Morbidity Database, 2013_2014, Canadian Institute for Health Information

THE IMPACT OF COPD ON HOSPITALS

062516_HN_EDIT.indd 3 2016-07-05 2:17 PM


4

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he case of ‘too much medica-tion’ in Canadian seniors is fi nally starting to be recog-nized for the serious problem

it has become. Seniors are particularly vulnerable to the adverse effects of too many prescription drugs because aging affects their ability to process medica-tions. Working aggressively to reduce their daily medication burden may be the single best thing we can do to improve the quality of life of our aging parents and grandparents.

The statistics behind polypharmacy in the elderly – the term that describes the simultaneous use of multiple medications – are surprising. In Canada, nearly 70 per cent of all seniors take fi ve or more drugs and almost 10 per cent take 15 or more medications.

Many hospitalizations in the elderly are caused by adverse medication reac-tions. And one of the biggest health haz-ards for seniors is falling – often a result of multiple medications which can cause cognitive diffi culties and affect balance.

The good news is awareness of the scale of the problem is growing. More and more physicians are initiating “depre-scribing” discussions with their older patients. “Deprescribing” is exactly how it sounds – the deliberate and conscien-tious stopping or tapering of prescriptions to help improve health outcomes.

Some long-term care facilities are now required to do periodic medication re-views and weed out unnecessary, ineffec-tive or hazardous pills. A recent massive Canadian Foundation for Healthcare Improvement demonstration project has shown how to reduce the inappropriate prescribing of antipsychotic medications to seniors with dementia.

Programs, research initiatives and phy-sician education activities on deprescrib-ing are being carried out in most provinc-

es. Canada’s new Deprescribing Network is developing tools and information to help make deprescribing commonplace and part of the prescribing culture.

This is all a step in the right direction. Unfortunately, there’s still reluctance in some quarters to cut back on medications.

Some health care providers have shown themselves to be nervous when initiating deprescribing activities, worried that they are reducing medica-tions that specialists or other doctors have ordered.

Publicly funded “medication reviews” conducted by pharmacists can be fl awed too, a CBC Marketplace investigation has found. Some reviews may be motivat-ed by potential business reasons, result-ing in more, not fewer pills for patients. The same report noted that even when done properly, medication reviews often miss the very patients who would benefi t most from a review, such as the elderly or people on a high number of medications.

More than 90 per cent of seniors say they want to reduce their medications if a doctor suggests it. And who can blame them? No one wants to be on a poten-tially expensive medication with pos-sible side-effects and possible risks if they don’t absolutely require it.

So what should be done?

Consumer-oriented literature on med-icine tends to focus on ‘adherence’ and ‘compliance’ to medications and not nec-essarily more appropriate drug treatment. And we can’t forget that pharmaceutical manufacturers have a business incentive for volume and are not rewarded for ap-propriateness of prescribing.

Thankfully, the folks from the Cana-dian Deprescribing Network have identi-fi ed a few areas where they see the harms of drugs often exceeding the benefi ts. These include, but are not limited to, benzodiazepines and other sedative med-ications (commonly prescribed for sleep-ing), proton pump inhibitors (to treat ul-cers and heartburn) and sulphonylureas (to treat type-II diabetes).

Drugs that can be problematic in combination with other medications in-clude those that treat blood pressure and glucose, where high doses of multiple medications can lead to problems. They also fl ag the over-use of blood thinners – which require appropriate monitoring. According to the Network, these are good places to start a consultation with your doctor.

As people get older they should con-stantly ask if a new medication is going to affect the things that are important to them: their mobility, cognitive abilities and capacity to enjoy life.

Caregivers and seniors, most impor-tantly, have to be ready to assert their wishes when it comes to taking too many medications and always be alert to the possibility that more medication might mean more problems. nH

Alan Cassels is an advisor with the Evidence Network and a pharmaceutical policy researcher. He’s the author of The Cochrane Collaboration: Medicine’s Best Kept Secret.

By Alan Cassels

T

In Canada, nearly 70 per cent of all seniors take fi ve or more drugs and almost 10 per cent take 15 or more medications.

Combating the over-medication of seniors

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062516_HN_EDIT.indd 4 2016-07-05 2:17 PM


5 CARDIOVASCULAR CARE/RESPIROLOGY/DIABETES/COMPLEMENTARY HEALTH Focus

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Use products as directed.

062516_HN_EDIT.indd 5 2016-07-05 2:17 PM



team of clinicians at St. Mi-chael’s Hospital is testing a new way to assess patients for diabetic peripheral neuropa-

thy, a loss of sensation in the feet that can result in an inability to feel pain.

Between 60 and 70 per cent of indi-viduals with diabetes lose sensation in their feet, increasing their risk of foot ulcers, which can lead to infection and leg amputation.

The most common test for neuropathy is the monofilament test, which involves

placing an instrument similar to a fishing line on areas of the foot, and asking if the patient feels sensation. But a much simpler test, called the Ipswich Touch Test, could be carried out at no cost, without the use of a special tool.

“This test could be used anywhere by anyone, meaning there would be no rea-son not to check patients with diabetes for neuropathy,” says Ann-Marie McLaren, a chiropodist in the Wound Care Depart-ment, who proposed and developed the study. “We’re looking for a tool that can easily identify people with loss of sensation who are at risk for developing a foot ulcer.”

The Ipswich Touch Test, developed by Dr. Gerry Rayman in the U.K., involves examiners using their index finger to touch the tips of the patients’ first, third and fifth toes on both feet in a particular order. Patients are asked to close their eyes and identify when the toe is touched.

“About 85 per cent of people who get their legs amputated had a diabetic ul-cer, which they developed because they couldn’t feel their feet,” says Suzanne Lu, a chiropodist in the Mobility Program. “If we can put into practice a simple as-

sessment tool, that means we could start catching people who have neuropathy ear-lier on, and prevent these kinds of things from happening.”

The study team trained 16 clinicians to use both the Ipswich Touch Test and the monofilament test on eight diabetic patients at St. Michael’s. The team is try-ing to validate the Ipswich Touch Test to determine whether it could be used in various clinical settings among dif-ferent healthcare professionals includ-ing nurses, chiropodists, occupational therapists, physiotherapists, dieticians and physicians.

“We want to see if we can get agreement between the monofilament and Ipswich Touch tests, and see if the touch test works between different healthcare practitioners, across different clinical areas,” says McLar-en. “With simple screening methods, early recognition of loss of sensation, education and appropriate referrals, we can prevent patients from developing foot complica-tions and save limbs – that’s the ultimate goal.” nH

Corinne Ton That works in communications at St. Michael’s Hospital in Toronto.

Testing new ways to screen for loss of sensation in

By Corinne Ton That

A

Suzanne Lu, a chiropodist in the Mobility Program , and Ann-Marie McLaren, a chiropodist in the Wound Care Department, perform the Ipswich Touch Test, which involves examiners using their index finger to touch the tips of the patients’ first, third and fifth toes on both feet in a particular order.

diabetic patients

• Patients are asked to close their eyes

• Examiners lightly touch three toes on both feet

• Toes are touched in a particular sequence using the index finger

• Patients are asked to indicate if they feel the examiner’s finger on their toes

How it works: the Ipswich Touch Test

Photo courtesy of Yuri Markarov, Medical Media

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7 Ethics

HospitalNews_4.9x13.44_Final

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e’re here now in the land of as-sisted dying as one option for those eligible for and in need of quality end-of-life care. An

evolving practice context that must re-spond to those distressing requests to end someone’s intolerable suffering (and other criteria as any new law stipulates). In re-sponse to this new situation, the Ministry of Health and Long Term Care has help-fully begun a voluntary registration pro-cess for physicians to log their position on involvement in elements of assessing for and providing assisted dying. This will hopefully help connect willing clinicians with those needing their assistance while allowing those not willing to either regis-ter as such or remain quiet, as their con-sciences direct them.

In thinking about how conscience en-ters the realm and deliberations around assisted dying, it is evidently a key factor for all. For those who actively participate, for those who facilitate in various ways and for those who object to any involve-ment, conscience will lead us each to our ‘last, best judgement’, as Charles Curran described it. Conscience is multi-factorial – coming from within and outwith, to bor-row a Scottish word. Sometimes what we feel most at ease doing is not what those external guideposts tell us to do.

In reaching our decisions, many will rely on faith. By faith I do not mean re-ligion, per se, but belief in some more su-pernatural or divine entity which can offer guidance to those seeking direction from outside the realm of the human. This is of-ten very distinct from organized religion.

For others, it is their connection with more formal religious institutions that offers additional direction and guidance. For some, religion may be the most cen-tral or even sole consideration – religious leaders and laws indicate decisively what is right and wrong.

Many will look to their own secular understanding of morality to help them

discern what would be the most ethical action in any situation. This may be in ad-dition to faith or religion, or it may be the primary source of one’s sense of what is the right thing to do.

In any of these cases, we may not feel particularly comfortable with what we are called to do by the sum of our delibera-tions and discernment. In the case of as-sisted dying, I know of no one who feels good about the idea. For those who feel it is lamentably right, that sense of right might at times appear to have an air of enthusiasm. However, from all I know of colleagues who have been arguing in fa-vour of access to assisted death, it is with a clear lament that they do so.

Pondering or encountering patients whose illness leads to contemplating an assisted death is and should always be gut wrenching – the ‘yuck factor’ in extremis. It is invariably something of a last resort option when all else seems to be ineffec-tive in achieving what the patient seeks from care. In this unfortunate context, death is good, counter-intuitively good.

When one looks from a distance, there is broad overlap in our shared aims in achieving a patient’s goals of care, par-ticularly remediating intolerable suffering. There are also clear differences of opinion on how best to shape this new practice as it becomes part of our reality. Our own moral and ethical guideposts will present each of us with certain preferred param-eters in the broader landscape of options that are now legally open to patients. The right of providers to practice within those differing parameters is also protected by law.

Together, relying on each other to step in where some of us as individuals might feel we cannot go, we can, as a broad col-laborative system, offer eligible capable and informed patients all the options they may wish to pursue to achieve their own goals of care. Such decisions by patients will also be very conscientious ones – in-formed by their own guideposts – their own unique combination of values, faith and/or religion. Where they pur-sue the option of assisted death through to its provision, it will be their own last, best judgement. nH

Kevin Reel is Assistant Professor, Department of Occupational Science and Occupational Therapy Faculty, Global Institute for Psychosocial Palliative and End-of-Life Care Member, Joint Center for Bioethics, University of Toronto.

Matters of conscience and end-of-life care By Kevin Reel

W

Pondering or encountering patients whose illness leads to contemplating an assisted death is and should always be gut wrenching – the ‘yuck factor’ in extremis.

Participation, facilitation and objection

062516_HN_EDIT.indd 7 2016-07-05 2:17 PM



s a registered respiratory ther-apist, Burnaby Hospital’s Dar-win Chan is proud to say that he’s there with patients from

their first breath to their last. Some days, the professional practice

leader of respiratory services in B.C.’s Fra-ser Health region attends births and re-suscitates newborn babies. On others, he stands at the bedside of ailing patients and is the one to turn off the machine when doctors and families agree hope is gone. And then there are times when he works right in the gap between death and new life, performing tests and compressing oxy-gen into an organ donor’s lungs to ready them for transplant to a grateful recipient.

“For a long time in CPR, we used the acronym A-B-C to stand for Airway, Breathing and Circulation. I like to say respiratory therapists are involved in the ABCs of life. And that’s precious,” ex-plains Chan.

Chan has been a respiratory therapist for 11 years, and says the diversity of the work has meant he’s constantly growing in his field. Over the course of his career, he’s worked across the BC Lower Mainland in hospital acute care, in diagnostics at pul-monary function labs, and in home care as an educator in the community. Chan joined Fraser Health in 2005, working at Eagle Ridge, Royal Columbian and Peace Arch hospitals, before taking over as pro-fessional practice leader at Burnaby Hos-pital in 2015.

“Because of my experience,” Chan says, “I understand a patient’s journey from home to diagnostic services to hospital so I know how help them cope at home to avoid readmission to hospital.”

In a typical day, Chan spends his time doing rounds with patients, reviewing their care, medications and conditions, performing procedures that range from intubations to tracheotomies, support-ing surgical and trauma patients, and re-sponding to Code Blue emergencies.

“A lot of what we do involves working closely with doctors and nurses,” Chan said. “There is no hero in healthcare. It’s not like TV where one doctor saves the day. In real life, it’s about teams. You’re al-ways trying to support each other.”

“In this job, you really need to work well with others,” he explains. “Good time management skills are important so you can prioritize patients and juggle emer-

gencies. With an aging population and seasonal respiratory illnesses, it can get very busy. It’s never boring.”

Aside from the clinical component of respiratory therapy, Chan enjoys being involved in patient education, teach-ing patients about quitting smoking, how to correctly use medications, and how to manage chronic lung diseases such as asthma and chronic obstructive pulmo-nary disease (COPD).

It’s this variety in respiratory practice that first attracted him to the field. When he graduated with a Bachelor of Science degree from UBC in the early 2000s, Chan wasn’t sure what he wanted to do. Then a friend told him about respiratory therapy and he was struck by the fact that he could be “involved in the whole spectrum of healthcare.” He earned his RT degree in a two-year fast-track diploma program at Thompson Rivers University in Kamloops, B.C. and found a job right after graduation in 2005: respiratory therapists are in high demand.

They should continue to be. Service Canada’s latest April 2015 job outlook for respiratory therapists is bright. According to the federal agency, the rise in the inci-dence of respiratory diseases coupled with an aging population and increase in out-patient care means the number of gradu-ates with a diploma in respiratory technol-ogy is currently “insufficient to meet the demand for respiratory therapists, espe-cially outside the urban areas.”

But for Chan, job security comes sec-ond to the daily rewards of his job.

“It’s a good field because you really get to see we make a difference,” Chan says. “Many times when we first see a patient they’re very sick on a breathing tube. The next thing you know you’re visiting them at home and they’re up and walking and you think wow, we really do help people get back to their normal life.” nH

Elaine O’Connor is a senior communications consultant at Fraser Health.

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Continued on page 9

Respiratory therapists give the breath of lifeBy Elaine O’Connor

A

Darwin Chan is a respiratory therapist at Burnaby Hospital in British Columbia.

hanks to an innovative new technology at Rouge Valley Health System (RVHS), com-mercial pilot Stephen Wilcox

is flying high – literally.Previously grounded by a heart arrhyth-

mia, or irregular heartbeat, he is clear to fly once again.

“At night, I would lie on the pillow, and hear my odd heartbeat missing beats,” says the 54-year-old Durham resident. “After I would have an episode like this, my heart would pause for several seconds before fi-nally going back to beating normally.”

Wilcox was suffering from a type of ar-rhythmia called atrial fibrillation, or AF, which occurs when there is disorganized electrical activity in the top chambers of the heart, causing an irregular heart rhythm. This can lead to a feeling of racing heart rate, irregular or skipped heartbeats, fatigue/tiredness, shortness of breath, chest discomfort, dizziness, and even fainting.

Thanks to the new cryoballoon abla-tion therapy procedure offered through the Central East Regional Cardiac Care Program, patients like Wilcox can now get care closer to home. This procedure is spe-cifically designed to treat AF, using freez-ing to treat the specific heart cells that are causing the abnormal beating. A balloon catheter is inserted into the affected heart chamber, and is inflated and filled with liquid nitrous oxide. This freezes the bal-loon, which is in contact with the targeted heart tissue. Often 3D-mapping technol-ogy will also be used to visualize the inside of the heart and precisely guide the balloon and ablation. The procedure is fast and effective, and can minimize radiation and anaesthesia.

This specialized service is performed at the regional cardiac care centre located at Rouge Valley Centenary (RVC) hospital campus in Scarborough, Ontario, which features three catheterization labs and a designated procedure room for arrhythmia treatments. This is where Stephen Wilcox was referred to and treated by RVHS car-diologist Dr. Derek Yung, who along with cardiologist Dr. Bhavanesh Makanjee, are amongst the most experienced operators with the cryoballoon in the province. Dr. Makanjee and Dr. Yung work in collabora-tion at the cardiac centre with Dr. Amir Janmohamed, cardiologist and manager of arrhythmia services at RVHS, and Dr. Ted Davies, cardiologist with The Scarborough Hospital.

By Jane Kitchen

T

Putting hearts in rhythm

Cardiologists Dr. Bhavanesh Makanjee (left) and Dr. Derek Yung in one of the cardiac catheterization labs.

062516_HN_EDIT.indd 8 2016-07-05 2:17 PM



he world-renowned Firestone Clinic at St. Joseph’s Health-care Hamilton is fi nding new ways to help nearly three mil-

lion Canadians diagnosed with asthma.Ground-breaking new treatment op-

tions through research at St. Joseph’s Healthcare Hamilton are now being ap-proved by Health Canada and the FDA.

The prevalence of asthma has been in-creasing over the past 20 years. While the causes of asthma aren’t known, the disease affects almost 15 per cent of children be-tween the ages of four and 11.

In Canada, asthma accounts for approx-imately 80 per cent of chronic disease cas-es and is a major cause of hospitalization in children. Approximately 90 per cent of children diagnosed with asthma also have allergies.

A series of clinical trials led by research-ers at St. Joseph’s Healthcare Hamilton have validated new medications that improve upon traditional treatments for asthma.

Testing new treatments for severe asthma

A new, antibody-based medication named mepolizumab can replace tradition-al, steroid-based treatments for a subset of patients with severe asthma, improving control of asthma symptoms without side effects.

Previous research at St. Joseph’s Health-care Hamilton has identifi ed that a sub-set of patients with severe asthma have an overabundance of particular type of white

blood cells (eosinophils) present in their sputum. These patients often suffer from the most severe asthma symptoms and can only be treated through steroid-based treatments such as high dose prednisone, causing side effects such as mood swings, diabetes, bone loss, skin bruising, cataracts and hypertension.

Subsequent research has successfully evaluated mepolizumab as a new treat-ment for severe asthma. St. Joseph’s Healthcare Hamilton served as one of the recruiting sites for this global trial, recruit-ing the maximum number of patients for a single site.

“This is an exciting example of per-sonalized medicine for asthma,” says Dr. Parameswaran Nair, respirologist at St. Joseph’s Healthcare Hamilton, professor at McMaster University and study author. “Our research suggests that by using a simple blood or sputum eosinophil count, we can identify which asthma patients can benefi t from this new treatment. Rather than risking severe side effects through high doses of prednisone, we can precisely target the protein that brings these white blood cells into the lungs.”

In late 2015, mepolizumab was ap-proved for administration in Canada and the United States – providing physicians and respirologists with a new way to treat severe eosinophilic asthma. The technique of quantifying infl ammation in sputum, a test pioneered by the late Professor Fred-dy Hargreave, contributed as much if not more than novel therapies to managing severe airway diseases. St Joseph’s Health-

care Hamilton is the only centre in Canada that offers unrestricted access to this test for patients.

Relieving allergic asthma with antibodies

Another antibody-based treatment developed and successfully tested at the Firestone Clinic at St. Joseph’s Healthcare Hamilton improves quality of life for indi-viduals with mild allergic asthma.

Today, individuals with allergic asthma are typically treated with inhaled cortico-steroids or bronchodilators that help to control their asthma when taken regularly. This new medication provides a new treat-ment option for those with allergic asthma that have issues with inhalers or steroid-based medications.

Named AMG 157, the new medication reduces lung constriction and infl amma-tion by suppressing a protein called thymic stromal lymphopoeitin (TSLP). By block-ing this protein, the antibody both allevi-ates baseline infl ammation and provides resistance to allergens.

“It was known that the epithelial cells which line the airways in the lungs produce

a protein called TSLP that causes infl am-mation,” says Dr. Paul O’Byrne, respirolo-gist at St. Joseph’s Healthcare Hamilton, Chair of Medicine at McMaster Univer-sity and study author. “Our work, for the fi rst time, proved that these cells continu-ally produce this protein in humans with asthma.”

Multicentre trials led by researchers at St. Joseph’s Healthcare Hamilton evaluat-ed the effectiveness of this antibody-based treatment – establishing proof-of-concept and moving this medication into phase two clinical trials.

Successfully evaluating new antibody-based treatments for asthma enables physi-cians and respirologists to provide effective treatment to patients without negative side effects of conventional treatment. This has the potential to transform care across Canada and around the world.

Dr. Nair and Dr. O’Byrne continue to work alongside fellow researchers at the Firestone Clinic to improve care for asth-ma and other pulmonary diseases. nHSebastian Dobosz is a Research Communications Offi cer at St. Joseph`s Healthcare Hamilton

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Helping Canadians to breathe easierBy Sebastian Dobosz

T

Photo courtesy of Jon EvansDr. Paul O’Byrne’s research helps to improve the quality of life of patients diagnosed with asthma.

Continued from page 8

“We want to get the message out – if you have symptoms like palpitations or faint-ing, talk to your doctor for a referral,” says Dr. Makanjee. “The cryoballoon ablation procedure is quick, safe, and effective.”

For Wilcox, the procedure was a perfect success, giving him relief when other ther-apies and treatments could not. “The pro-cedure was a very positive experience for me. Within six months of the diagnosis, af-ter having what felt like every test known to man, thanks to cryoballoon ablation the problem was solved. How does it get better than that?”

Patients with AF or who are experienc-ing issues of irregular heartbeat should discuss their condition with their family doctor, and can contact the arrhythmia

management clinic at RVHS at 416-284-8131 ext. 5327 to learn more about ar-rhythmia services or if cryoballoon abla-tion therapy is right for them. nHJane Kitchen is the communications specialist at Rouge Valley Health System.

Putting hearts in rhythm

Commercial pilot Stephen Wilcox in the hangar at Oshawa Airport. Previously grounded by a heart arrhythmia, he can fl y again thanks to cryoballoon ablation therapy.

062516_HN_EDIT.indd 9 2016-07-05 2:17 PM



aving his golden years turn into gasping years was getting hard for retired RCMP officer Bruce Davis, once an exceptionally fit

man who also protected Alberta premiers during his years of service.

“I used to have a treadmill at home and work out all the time,” says the 80-year-old Edmontonian. “But in recent years, my quality of life wasn’t good. I tired eas-ily. I puffed on the stairs. I wasn’t inter-ested in anything. Life had become a drag. All I could do was sit in a chair and read the paper.”

Davis was one of many seniors living with shortness of breath, fatigue and heart failure due to a leaky mitral valve – but who are too frail or high risk for open- heart surgery.

In a heartbeat, his life changed for the better this past March when he underwent a new leading-edge repair procedure that has seen him regain his health and vitality. “It was painless. I didn’t feel a thing,” he says. “I had good success with that. I’m do-ing much better.”

His wife Kathy, a retired RN, recalls: “Before his surgery, gradually he became weaker and weaker, and less likely to get

out of his chair. But right after his surgery, when he woke up, I could see colour in his cheeks for the first time in years.”

Dr. Kevin Bainey, an interventional cardiologist at the Mazankowski Alberta Heart Institute (Maz), says: “These people can’t even walk a block without being short of breath. With our new valve-clip proce-dure, we can improve upon that. Before this procedure, there were no other options for patients who could not have open- heart surgery.”

Their condition, known as mitral regur-gitation (MR), is one of the more common types of heart valve disease, affecting nearly one in 10 people aged 75 years and older. It occurs when the flaps of the heart’s mitral valve – situated between the main pump-ing chamber, the left ventricle, and the left atrium, which receives all the blood from the lungs – fail to close completely, causing blood to flow backward into the left atrium and into the lungs.

To compensate and keep up blood flow through the body, the left ventricle pumps harder, straining the heart. Symptoms of MR include: shortness of breath, fatigue, coughing, lightheadedness and swollen feet or ankles. MR also raises the risk of irregu-lar heartbeats, stroke and congestive heart failure, which can be life-threatening.

“Instead of having to open the chest, we can now repair the valve in a minimally-in-vasive way, using catheters inserted in the groin to guide the valve clip in place on the failing valve,” says Dr. Bainey. “This device grasps the valve flaps to close the centre of the valve, leading to relief of symptoms. Pa-tients usually go home the next day, feeling much better.”

“Historically, these patients have been treated with surgery,” adds Dr. Ben Tyrrell, an interventional cardiologist with the CK

Hui Heart Centre at the Royal Alexandra Hospital. “But often their heart muscle is just so weak that they’re not able to toler-ate open-heart surgery, which also means they’re not candidates for a heart trans-plant or a mechanical heart, either.”

Teamwork between the Maz and the CK Hui has helped to bring the new procedure to Edmonton. To date, the pilot program has seen six patients undergo the proce-dure, which isn’t for everyone.

“It’s still a niche procedure right now,” says Dr. Tyrrell. “There are lots of anatomi-

cal considerations in picking the right pa-tients for this catheter approach. There are tried-and-true surgeries that are still great therapy for a lot of patients.”

While surgical MR patients can expect to spend five to seven days in hospital, fol-lowed by three to six months of healing at home, valve-clip patients fully recover and go home within a day.

Meanwhile, on the research front, Ed-monton will soon help to pioneer the re-placement, via catheter, of the entire mitral valve with a newly-developed synthetic valve. The procedure is likely to be per-formed in the near future once a suitable patient has been identified.

“We’re part of an early feasibility study that was recently approved by Health Can-ada,” says Maz cardiac surgeon Dr. Steve Meyer. “We’re one of only three sites in North America doing this.”

Maz cardiologist Dr. Robert Welsh, Ed-monton Zone Clinical Department Head for Cardiac Sciences, says: “Minimally invasive approaches to valve therapy are revolutionary therapy. These technological advances are allowing us to improve qual-ity of life for this important and growing patient population.”

Kathy Davis, married to Bruce for 55 years, says she’s thrilled with her husband’s new energy. “He now likes to get up and do things around the house. Last week we went for a kilometre walk. The other day he went outside and decided to sweep the deck. It’s been an enormous change.”

For his part, Davis adds: “While a valve repair may seem like a little thing, Dr. Ba-iney and his team have literally given me years more to enjoy with my grandchildren, my wife and my family. My ticker’s strong and I’m breathing easy now.” nH

Gregory Kennedy works in communications at Alberta Health Services.

High-tech heart-valve heals seniors too weak for open-heart surgeryBy Gregory Kennedy

H

While surgical MR patients can expect to spend five to seven days in hospital, followed by three to six months of healing at home, valve-clip patients fully recover and go home within a day.

Interventional cardiologist Dr. Kevin Bainey poses with patient Bruce Davis, 80, and his wife Kathy. Davis recently underwent a new mitral-clip procedure to repair his leaky heart valve.

062516_HN_EDIT.indd 10 2016-07-05 2:17 PM



very year in Canada over 25,000 pacemakers and inter-nal defibrillators are implant-ed in Canada and according

to the Canadian Journal of Cardiology over 200,000 Canadians have permanent pace-makers or implantable defibrillators. De-mand for these devices is only expected to grow given the link between aging and the indications necessitating these devices, such as bradycardia, combined with our shifting demographics in Canada.

Until 2012, pacemaker and MRI manu-facturers instructed physicians not to scan patients with pacemakers, as this exposure could disrupt a pacemaker’s electronic sys-tem and burn surrounding tissue.

As a result, an MRI was not usually considered for patients with a pacemaker. However, a study published in The Japanese Heart Journal showed that an MRI pro-cedure is requested by a physician for 17 per cent of pacemaker patients within 12 months of device implant.

Four years ago, the landscape changed when Medtronic introduced Advisa, the first MRI conditional pacemaker that had been designed, tested, and licensed by Health Canada for use as labeled with MRI machines. Patients with the Advisa pac-ing system have access to full body scans, without positioning limitations in the MRI scanner.

Since then, physicians such as Dr. Vi-kas Kuriachan, cardiologist and cardiac electrophysiologist at the Libin Cardiovas-cular Institute of Alberta, and University of Calgary are faced with deciding which patients are the more likely candidates for an MRI conditional pacemaker or implant-able defibrillator.

The statistics provide a strong argu-ment for MRI conditional devices. Dr. Kuriachan reports that up to 10 per cent of the population in Canada might get an MRI every year. “If you specifically look at patients with cardiac implantable devices, the estimate is 50 to 75 per cent of them will need an MRI in their lifetime. And the reasons can be quite variable. MRIs are a crucial test for diagnosing problems in the neurological, muscular skeletal and even cardiac systems. These include things like stroke, brain tumours and sometimes more common problems such as investigating back or joint pain. So we want to be pre-pared for that.”

In addition, MRIs are the preferred op-tion for soft tissue imaging as they provide more detail than modalities such as CT or ultrasound. “An MRI can give images that cannot be found with other imaging,

especially for certain brain tumours, cer-tain strokes that you couldn’t see, as well as certain spine, joint and cardiac muscle problems,” Dr. Kuriachan says.

The historic concern of scanning a pa-tient with a pacemaker was indeed a legiti-mate safety concern, he adds “I think the first thing to keep in mind is these devices are designed to be MRI conditional. And we have lots of studies now including clini-cal studies that show that they’re safe to use in the appropriate MRI environment and condition.” He also stresses that the Canadian Heart Rhythm Society and the Canadian Association of Radiologists have a joint consensus statement published in

2014 that specifies the appropriate proce-dures to be followed when scanning a pa-tient with a MRI conditional pacemaker. Ultimately Dr. Kuriachan believes that beyond the diagnostic benefits, MRI con-ditional devices improve efficiency and patient care. “The MRI scan can offer ad-vantages that other testing cannot so there are certain conditions where the diagnosis can be reached with an MRI scan but not necessarily by some of the other tests. So if you have a patient with an MRI condition-al device, they can get the MRI scan and have the answer with the one test. Other-wise they may need multiple tests and still not have the answer.”

Alan, a patient from Calgary is a case in point. A recently retired government em-ployee, he suffered a mini-stroke. When sent for an echocardiogram and carotid artery ultrasound, it was discovered he had atrial fibrillation. Further checking revealed that his pulse had been dropping into the 30s, a problem that could be re-solved with a pacemaker.

He notes that when the decision was made, “I had no idea at that point that there was anything that was even com-patible with an MRI. It never occurred to me that there were different kinds of pacemakers. I just trusted my cardiologist to pick the right one for me.”

The decision was a fortuitous one. A stress test and CT scan picked up anoma-lies on his liver. A subsequent ultrasound also indicated something was wrong in his pancreas which could only be diagnosed with an MRI.

“I’d never thought my pacemaker could prevent me from getting an MRI,” Alan says. “But my family doctor knew I had a pacemaker that was compatible with the MRI. With a different pacemaker that wasn’t MRI conditional I would probably have felt cheated because I know that the MRI is so important in diagnosing some conditions.”

Given the advances in pacemaker tech-nology and the diagnostic capabilities of MRIs, the hope for patients like Alan is that more physicians, cardiologists, and MRI technicians will become more knowledgeable about MRI conditional devices so that their patients can also ac-cess the benefits of both pacemakers, and MRI scans. nH

Melicent Lavers-Sailly leads PR and Communications at Medtronic Canada.

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MRI conditional pacemakers improving patient access to diagnostics By Melicent Lavers-Sailly

E

If you specifically look at patients with cardiac implantable devices, the estimate is 50 to 75 per cent of them will need an MRI in their lifetime.

Alan’s pacemaker is MRI compatible, a relief when he learned he would require an MRI to diagnose abonomalies on his liver.

062516_HN_EDIT.indd 11 2016-07-05 2:17 PM


12 From the CEO's Desk

It started with a fall. That’s how 80-year-old ‘Sandy Pine’ found herself in the Emer-gency Room at Campbellford

Memorial Hospital.Sandy is one of a growing number of

seniors treated at the Emergency Room of Campbellford Memorial Hospital (CMH), a 34 bed hospital that serves Northumber-land, Peterborough and Hastings County residents, largely a rural community with a population of approximately 30,000 people plus seasonal visitors who come to stay at their cottage.

Patients like Sandy present a particular challenge for the team at CMH. Sandy, who lives in a remote area, fell on the ice and was admitted to CMH with a fractured hip. Unable to move for four weeks, she was intent on returning to her home once she was mobile again. Hospital staff how-ever were faced with a dilemma around her discharge and return home. Sandy lived alone in poor housing conditions with no family or community support in a very re-mote area. She did not have a family phy-

sician and she had previously refused the services of Community Care.

CMH is increasingly supporting patients like Sandy. This kind of situation presents a real challenge both ethically and in terms of resources for CMH. It is a challenge an-ticipated to grow into the future especially with the growing number of seniors mov-ing into the area.

In Northumberland County, between 2006 and 2012, the age-group with the greatest percentage increase in popula-tion was the 85+ age-group (a 27.9% in-crease). By 2034, the population aged 65 and up is projected to increase by 94 per cent, including a more than doubling of the number of resident’s aged 85 years and up, compared to 2012 estimates. Canadi-ans are living longer and in good health but the risk of developing a chronic condi-tion increases with age, especially for indi-viduals aged 80+.

For CMH this means we are treating more patients with higher acuity living with multiple chronic diseases and requir-ing acute services as part of their overall healthcare plan. Many lack family and community support and the impetus to access healthcare before a health problem becomes a life-threatening issue.

Our vision is to be a recognized leader in rural healthcare, creating a healthy com-munity through service excellence, effec-tive partnerships and the development of innovative hospital partnerships. CMH’s receipt of a 2013 Platinum Quality Health-care Workplace Award from the Ontario Hospital Association shows the level of commitment we share in bringing this vi-sion to life.

We are demonstrating this leadership and our award-winning team is making a difference with our concerted effort to provide senior friendly care. Our aim is to enable seniors to maintain optimal health while they are hospitalized so they can re-turn home or transition to the next level of care that best meets their needs.

For example, we use a senior friendly approach to assess and care for seniors while fostering excellence. Treatment in-cludes helping patients like Sandy opti-mize physical function. This includes:• Restorative Care where a multidisci-

plinary team works closely with pa-tients, assisting them to reach their highest level of ability to support their return home;

• Use of a Frailty Assessment for Care-Planning Tool daily on each patient at interdisciplinary rounds as a change in-dicator.

• Senior friendly walkabouts with pa-tient experience advisors to review and change processes and our environment from an elderly patient point of view.

• Use of assessment tools like the Barthel Tool for functional decline to ensure el-derly patients at risk of falling get the most appropriate care.

• A falls prevention program for people who are interested in getting informa-tion to help prevent a fall at home or in the community.

• Palliative and Therapeutic Harmoniza-tion (PATH) approach to care for as-sessing frail, older adults who visit the ER and are admitted for treatment. This gives patients and their family’s time and space to make complex healthcare decisions that project their best inter-ests and quality of life. Delirium in an elderly patient can add

complication for the care team. A deliri-um, dementia, depression screening tool is completed in the ER. We’ve also educated our staff to recognize signs of delirium and responsive behaviours.

Our focus on senior friendly care ex-tends beyond the walls of the hospital and out into the community with a variety of

health service providers. Our patients now have access to a local Geriatric Assessment and Intervention Network (GAIN) team. GAIN teams provide specialized care to support frail older adults living at home, including retirement residences with mul-tiple complex medical problems including cognitive impairment, decreased function, falls or risk of falls, impaired mobility, in-continence and/or multiple medications. Frail older adults experiencing changes in support needs, safety concerns, psy-chological and mental health concerns or frequent health service usage benefit from the use of these services.

Ultimately, Campbellford Memorial Hospital is well-positioned to serve as a rural hub that brings together a variety of health service providers to support the needs of the aging population that defines our community. While much of our ef-fort is focused on patients receiving acute care, we are working collaboratively with a growing network of health service and community service providers to create a wrap-around web of support for our grow-ing senior community.

Most recently, our Board of Directors hosted a day of discussion around senior friendly care that brought together mem-bers from across our Region with a shared interest in achieving the best possible patient outcomes for our older commu-nity members. This is important because it brings a variety of organizations together to find new and innovative approaches to providing care for our community. I was pleased with the outcome of the day be-cause it supported our collaborative ap-proach to care for our seniors.

I’m proud of our team because they truly make our hospital a great place to receive care. It’s this level of commitment that enables CMH to ensure that pa-tients like Sandy get the care they need to return home with the supports in place to continue to live independently in the community. nH

Brad Hilker is President & CEO, Campbellford Memorial Hospital.

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Ensuring senior friendly care in a rural communityBy Brad Hilker

I

In Northumberland County, between 2006 and 2012, the age-group with the greatest percentage increase in population was the 85+ age-group (a 27.9% increase).

Brad Hilker

062516_HN_EDIT.indd 12 2016-07-05 2:17 PM



iven how much healthcare pro-fessionals have to do during di-abetes-focused appointments, from checking A1C levels and

eye health, to searching for potential foot ulcers, it’s not surprising that some aspects of their patients’ lives are rarely discussed. But if you ask people with the disease, one of the most important challenges is how diabetes affects them – an experience con-fi rmed by fi ndings in the 2013 Diabetes Attitudes Wishes and Needs (DAWN2) second study.

What’s more, 33 per cent of people with diabetes feel anxious about their diabetes, 28 per cent feel diabetes distress (the emo-tional impact specifi cally related to diabe-tes and its management), and 26 per cent feel overwhelmed, according to the Cana-dian Diabetes Association’s (CDA’s) 2015 Report on Diabetes: Driving Change. With research showing that people with the dis-ease are more likely to suffer from anxiety or depression, it may be time for health-care providers to spend time addressing the issue.

Twenty-fi ve-year-old Kylie Peacock is from Halifax, and has lived with type 1 dia-betes since she was eight years old. She says that while she now has a good team, many of the providers she worked with in the past just focused on the numbers, such as her blood glucose (sugar) targets, “without taking into account the daily stressors that can make attaining these goals diffi cult.”

Peacock wishes more healthcare pro-fessionals better understood the constant

pressure of dealing with blood sugar lev-els and the fear of going too high or low. “Effort doesn’t equal success in every case with type 1 diabetes,” she says. “I try my best every day to keep things managed and sometimes wish healthcare professionals knew the amount of effort I undergo to stay healthy.”

Edmonton-based Donna Graham lives with type 2 diabetes, which can involve similar emotional challenges. She feels lucky to have a supportive medical team, which has been essential in helping her manage the disease. “Living with type 2 dia-betes is mentally and emotionally exhaust-ing,” says the 60-year-old, adding that she

has had diffi culties with her weight, misun-derstandings about her diabetes at work, and problems getting adequate coverage for the diabetes medications she needs. “The everyday life of a person living with type 2 diabetes [can] require sacrifi ces and choices to maintain an acceptable blood sugar level,” she says.

So why are so many healthcare pro-viders overlooking their clients’ mental health? “Healthcare providers are busy, and they have a strong focus on non-men-tal health issues,” says Dr. Michael Vallis, a psychologist and one of the co-authors of the DAWN2 study, who speaks regularly about this topic for the CDA. But there is

a bigger barrier: discomfort. “Healthcare providers often talk about not wanting to ‘open Pandora’s box’ or ‘opening a can of worms’ ”

Another concern? “They fear that the patient will never stop talking, and [that] this will interfere with their ability to man-age their clinical time.”

Overcoming these barriers may seem diffi cult, but Dr. Vallis sees the connection between well-managed diabetes and good mental health as critical. “Diabetes and mental health should not be seen as two separate issues. While it is true that living with diabetes can increase the risk of major depression, the most important observa-tion is that living with diabetes is stressful,” he says.

Finding time to talk about emotional and mental well-being may be a challenge, but doing so can have a major impact on overall patient health. For more informa-tion or to read the entire Driving Change report, visit diabetes.ca.

“Almost half of those living with diabe-tes experience what we call diabetes dis-tress, and over 80 per cent of people living with diabetes report that it has a negative impact on some aspect of life. Managing the emotional experience in living with diabetes is of great importance both with respect to diabetes control as well as qual-ity of life.” says Dr. Michael Vallis. nH

Krista Lamb is a communications manager at the Canadian Diabetes Association.

Do you know how your clients with diabetes feel?By Krista Lamb

G

Dr. Michael Vallis

Diabetes and mental health should not be seen as two separate issues. While it is true that living with diabetes can increase the risk of major depression, the most important observation is that living with diabetes is stressful.

062516_HN_EDIT.indd 13 2016-07-05 2:17 PM


14 Cover Story

veruse is pervasive in health-care. Some healthcare provid-ers say they see it every day. For example, with every daily blood

draw that is routinely ordered for in-pa-tients that does not offer any clinical value to the patient or change their course of care.

Others refl ect on that one patient who was harmed, either physically or emotionally, by overuse. Like the patient who under-went a CT scan to rule out a pulmonary embolism, when a blood test would have suffi ced. Or the patient who has a routine chest x-ray that fi nds an incidental small lesion in the lung, leading to a CT scan, then a needle biopsy, then complications of the biopsy, only to discover in the end that the lesion is benign.

Estimates are that up to one third of medical care adds no value to patients. Over testing and treating our patients leads to unnecessary harm and wastes valuable healthcare resources.

Overuse is an epidemic in healthcare. From primary to acute care there are ex-amples of how we order tests and treat-ments, in spite of strong evidence that they do not help, and may even harm our patients.

Modern medical care is all about mak-ing choices. Weighing the potential harms and risks against the potential benefi ts to our patients and their wellbeing. Doctors do this every day, but generally, we err on the side of doing more, rather than doing less. We are often seeking a quick fi x to diffi cult problems.

For example, for that older patient who is having trouble sleeping, it seems like an easy solution to scribble off a prescrip-tion note for sedative medications. But, that small pill comes with big harms and dependency problems. We know that far too many elderly Canadians are tak-ing these drugs. The risks of these drugs include cognitive problems, falls and hospitalizations.

It is estimated that about 80 per cent of health care costs can be traced back to a doctor’s decision. However, the problem of overuse doesn’t just have to do with doc-tors’ choices.

Patients and their family members often request tests or treatments that offer no clinical value. These are generally well-intentioned. Patients are often fearful from hearing stories of healthcare problems of family and friends, or media coverage. They want to be reassured by a healthcare professional that they are well. We live in a society where ‘more is better’ and so we think that more healthcare means better health. Plus, healthcare providers are often under enormous time pressure in the clinic or at the bedside and often order tests or treatments that may not be necessary just to ‘cover all bases’.

The problem of unnecessary use of an-tibiotics is a symptom of this approach, and overuse is the cause. In Canada, of the over 23 million antibiotic prescriptions each year, about half are inappropriate and unnecessary. Overuse and misuse of antibi-otics comes with serious consequences for healthcare. The emergence of antibiotic resistant superbugs and patient complica-tions, like C.diff infections, has been seen with increased frequency in our hospitals.

Turning the tide on the epidemic of overuse requires a conversation from both sides of the exam table or bedside. While clinical practices need to change to stop using treatments or ordering tests that aren’t evidence based, so too do patient and public expectations. There is a need for more public awareness about the po-tential risks and side effects of over testing, overtreatment and too much medicine.

That is why the Choosing Wisely Cana-da campaign was launched in April 2014. Modeled after the United States’ Choosing Wisely campaign, Choosing Wisely Cana-da works with Canadian national specialty societies to develop lists of ‘Five Things Clinicians and Patients Should Question.’

These lists identify tests and treat-ments which are commonly used in each specialty, but are not supported by evi-dence and may expose patients to harm. To date, more than 175 recommendations have been released by over 30 medical specialty societies, with more to come, including lists created by and for nurses. There is also a list for medical education that was developed by Canadian medical student organizations.

While national specialty society rep-resentatives have worked on developing the recommendations, putting them into practice has been led by frontline clinicians and provider organizations from coast to coast. We want to share some examples of how recommendations are improving patient care and sparking innovation at the bedside.

Lose the tube Sunnybrook Health Sciences in Toronto, Ontario

The Hospital Medicine and Internal Medicine lists both include recommen-dations related to the inappropriate or unnecessary placement of urinary cath-eters. Dr. Jerome Leis, an infectious dis-ease specialist, conducted an audit and found that 18 per cent of admitted inpa-tients on the medicine unit had a urinary catheter even though 69 per cent lacked an evidence-based reason. Leis worked with nurses on the medicine unit to de-velop a medical directive to standardize removal of catheters when patients were transferred to the medicine ward. The team halved the rate of catheter use on the unit and signifi cantly reduced the rate of urinary tract infections since the medical directive was put in place.

Don’t give two when one will do Halifax, Nova Scotia

The Transfusion Medicine list includes a recommendation “Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients.”

In Halifax, a team from Capital Health modifi ed red cell guidelines developed for elective non-bleeding general hematology and bone marrow transplant patients.

This modest initiative had a major impact – it decreased the number of pa-tients transfused by 10 per cent, and was estimated to have saved $1.8 million dol-lars’ worth of precious blood over two years from 2012-2014.

Learn how to measure patient engagement & enhance patient experience amidst a world of change.

September 20 - 21, 2016 | Toronto, ON

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More isn’t always better: When less is more in medicine By Wendy Levinson and Karen Born

O

Continued on page 15

Superbugs are on the rise because of antibiotic overuse. Half of all antibiotic prescriptions are unnecessary.

Over 30% of long-term care residents in Canada are taking antipsychotic drugs without a diagnosis of psychosis.

As much as 30% of healthcare in Canada is unnecessary.

Cover Story

More isn’t always better:

062516_HN_EDIT.indd 14 2016-07-05 2:17 PM


15 Cover Story

Drop the pre-opManitoba

A number of national specialty society lists include recommendations against un-necessary pre-operative testing prior to low risk surgery. These tests, such as chest x-rays or ECGs prior to low risk surgery like a cataract replacement have been shown to provide no benefi t to patients.

Choosing Wisely Manitoba has focused on large-scale projects in the province that can improve patient care and reduce waste. They zeroed in on pre-operative testing. They set the goal of reducing pre-operative tests by one quarter by working directly with primary care as well as surgi-cal teams to improve information given to patients before surgery.

Further, pre-operative order sets and packages shared between physicians have been updated so that it is much more dif-fi cult to tick off a box for an unnecessary test. The next steps for this project include updated history physical exam forms from the provincial health authority as well as revised pre-operative guidelines.

Reducing unnecessary urine tests in the emergency departmentAlberta Health Services

The Canadian Psychiatry Association list includes a recommendation “Do not routinely order urine drug screen testing on all psychiatric patients presenting to emergency rooms.” This blanket approach to drug testing has not been shown to im-prove the care of psychiatric patients in

emergency departments. In fact, it can cause delays in assessment and manage-ment. In Alberta, there is a Strategic Clin-ical Network dedicated to addiction and mental Health. They chose to tackle stat drug toxicology tests in emergency depart-ments, and did so by providing education to providers and showing data around the pitfalls of stat toxicology tests. The imple-mentation resulted in a 96 per cent de-crease in testing over six months.

Less sedatives for your older relatives McGill University, Montreal, Quebec

A number of medical specialty societ-ies have a recommendation related to inappropriate use of powerful sedative medications, such as benzodiazepines, which are particularly harmful for older adults. These drugs are also very diffi cult to stop once started. For example, the Canadian Psychiatry Association recom-mends “Don’t use benzodiazepines or oth-er sedative-hypnotics in older adults as a fi rst choice for insomnia.” In Montreal, a community-based program to educate pa-tients about the harms of sedative hypnot-ic drugs like benzodiazepines was launched

in pharmacies to provide information to elderly patients, and their family members, about how to slowly taper off this drug. The intervention was successful in help-ing patients talk to their doctors and ask about how to decrease their use of these powerful drugs.

Asking the four questions to reduce overuse

The campaign is also engaging the pub-lic and patients, and has developed patient friendly information to go along with rec-ommendations, including over 30 patient pamphlets.

In addition to that, we wanted to give patients tools to talk to their healthcare providers. Four questions were developed as a way for patients to start the conver-sation. You may have seen these in your hospital, doctor’s offi ce or community lab. They spread the message that sometimes in medicine, as in life, more is not always better. 1. Do I really need this test, treatment or

procedure?2. What are the downsides?3. Are there simpler, safer options?4. What happens if I do nothing?

What you can do to help The task of reducing unnecessary care

and encouraging appropriateness is up to patients and clinicians. Patients can ask questions, and engage in conversa-tions about unnecessary care. Clinicians can drive improvement using the Choos-ing Wisely Canada recommendations to

inspire innovation and changes to work fl ows and processes leading to unnecessary tests and treatment.

Local context, practice and cultures vary widely across healthcare settings. We have seen tremendous impact when im-plementation is focused on local priorities, and there is a growing body of research and data detailing this.

Choosing Wisely Canada encourages and supports local ingenuity in the imple-mentation of recommendations. Our hope is that the stories of individuals and orga-nizationswho are doing so inspire you to look at where you can infl uence change locally. Reducing unnecessary care is in all of our hands, and together we can work to avoid harm and ensure high quality care for our patients, and our healthcare system.

To learn more, please visit www.choos-ingwiselycanada.org nH

Dr. Wendy Levinson is Chair of Choosing Wisely Canada and a professor of Medicine at the University of Toronto. Karen Born is Knowledge Translation Lead of Choosing Wisely Canada and an assistant professor at the University of Toronto.

70% of diagnoses can be determined from a medical history alone, without needing any tests.

Continued from page 14

The amount of radiation from one full-body CT scan is equivalent to 200,000 airport scans.

062516_HN_EDIT.indd 15 2016-07-05 2:17 PM



hen Elaine Fantham was di-agnosed with heart failure in 2013, she had questions: what could she eat? How could she

prevent further deterioration of her heart? To fi nd answers, she relied on printed bro-chures that explained the basics of heart failure and its effects.

Fast forward three years, while Elaine is waiting for her appointment in St. Joseph’s Health Centre’s Heart Function Clinic, she now just scrolls through a new online resource that has the latest information she needs to answer her questions and help inform the conversation she is about to have with her cardiologist.

The Ted Rogers Heart Failure Patient Education website (www.tedrogersheart-function.ca) is a brand new resource de-veloped by a St. Joe’s physician in partner-ship with the Peter Munk Cardiac Centre, University Health Network and the Ted Rogers Centre for Heart Research that is changing the way people get their health information.

“It makes me more comfortable know-ing this resource is available,” says Elaine.

“I would use it after speaking with my car-diologist if I had any questions. The videos are helpful – it’s very good if you can actu-ally see what’s being explained.”

Every year, more than 50,000 people are diagnosed with heart failure in Canada. The news can be unexpected and infor-mation that is shared during the fi rst few conversations between patients and their doctors can be diffi cult and overwhelming to absorb.

“We wanted a resource that patients could access on their own, when they were ready to learn more about their diagnosis,” says Dr. Peter Mitoff, a cardiologist at St. Joe’s who was the lead physician on the website. “We spoke with patients and the feedback we got was that they didn’t want to read about heart failure – they wanted to be able to visualize what’s happening in their body.”

The bright, bold website shares informa-tion through text, diagrams and videos. It provides a comprehensive look at what heart failure is, how it’s caused, what the treatments are and how someone with heart failure can live a healthy life.

“This is amazing for us as educators,” says Jennifer Comello, Registered Nurse in the Heart Function Clinic. “We’re work-ing to make this available on all patient monitors at bedsides so when we’re meet-ing with patients in the clinic or in their rooms, we can actually show them what we’re talking about; this will be so benefi -cial in terms of helping them understand their health condition and how to manage their diagnosis. Patients can also use the videos to talk about heart failure with their family when they go home.”

This website is an exciting patient edu-

cation resource that is helping to innovate and redesign our patient experience by giv-ing people the tools they need, where they need them, to help manage their health conditions.

This is just one of the many patient edu-cation resources being developed by our teams. Teaching and education is deeply ingrained in everything we do at St. Joe’s – learn more about our other initiatives by visiting www.stjoestoronto.ca. nH

Amber Daugherty is a Communications Coordinator at St. Joseph’s Health Centre.

Online educational tool launches for heart failure patients By Amber Daugherty

W

Elaine Fantham said she appreciates having the Ted Rogers Heart Failure Patient Education website available to her as a resource.

The Ted Rogers Heart Failure Patient Education website (www.tedrogersheartfunction.ca) is a brand new resource.

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062516_HN_EDIT.indd 16 2016-07-05 2:17 PM



hen Gordon Ying was admitted to North York General Hospital for a chronic obstructive pul-monary disease (COPD) flare-

up, he said it changed his life. Through the hospital, he enrolled in a new program that connects acute care (hospital care), com-munity care and primary care (e.g. fam-ily physicians), which taught him the tech-niques to take control of his condition.

Launched in March 2016, the North York Central Integrated Care Collaborative program for COPD focuses on coordinated care and communication between hospital, community and primary care providers dur-ing and after hospital discharge. With this program, patients with COPD will receive a coordinated approach to care that starts at North York General with a Clinical Care Consultant, and continues for up to eight weeks after discharge.

During the eight weeks, the Clinical Care Consultant, family doctor and community partners from Circle of Care, North York ProResp, Saint Elizabeth and West Park Healthcare Centre, work together with the patient and their family to ensure the right interventions are in place. This includes home assessments from a registered nurse within 24 hours, a respiratory therapist within 48 hours and a physiotherapist with-in the seven days. Patients are then enrolled

in either the Outpatient Pulmonary Reha-bilitation Program at North York General or home rehabilitation provided through the community partners.

Gordon was the first patient to be en-rolled in the program and on May 20, he completed the last Outpatient Pulmonary Rehabilitation class.

“Before I started this program, I couldn’t do what I am able to do today,” says Gor-don. “My appetite is better, I’m sleeping

through the night, I’m able to walk for lon-ger, and I don’t cough as much anymore. This amazing team of people helped me un-derstand COPD, taught me how to manage it, and the exercises through rehab helped me regain my strength to take control of my life again. I have already enrolled myself in another exercise class so I can maintain my health.”

Leigh Guertin is a registered respiratory therapist and the Clinical Care Consultant

for the North York Central Integrated Care Collaborative for COPD. She explains that patients with COPD or a chronic disease of-ten need more care and attention. By ensur-ing patients receive the right education and supports, at the right time it can make a big difference in their quality of life.

“We see a lot of patients who say they know they have COPD but are unsure about what it is or what to do,” says Leigh. “When patients are diagnosed or in hospi-tal, they are getting a lot of information, usu-ally during a difficult time. This often means understanding the diagnosis and following through on appointments and treatments are less likely. We are trying to reverse that process by delivering education and strate-gies to manage their COPD over an eight week period, during their recovery.”

Leigh says the collaborative approach be-tween acute, community and primary care is the strength of the program. Through de-veloping the program, these organizations were able to come together and breakdown some of the siloes and barriers between pro-viders at different points of care for COPD. The results are a seamless transition of care for patients as they recover, and for patients like Gordon, to see COPD as being a man-ageable part of his life rather than defining it, and staying out of hospital. nH

Priscilla Hsu is a Communications Officer at North York General Hospital.

New program making a world of difference for COPD patientsBy Priscilla Hsu

W

Gordon Ying at his last Outpatient Pulmonary Rehabilitation class with Leigh Guertin, Clinical Care Consultant for North York Central Integrated Care Collaborative program for COPD.

062516_HN_EDIT.indd 17 2016-07-05 2:17 PM


18 Evidence Matters

stroke can be devastating for patients and their families. Seeking immediate treatment as soon as you recognize the

symptoms of a stroke can go a long way in preventing long-term consequences or death. However once you have experi-enced a stroke, the risk of having another is very real. But what if there was a test that could help determine if you have a condition putting you at increased risk of another stroke?

Atrial fibrillation – or AF – is an abnor-mal heart rhythm. Because the heart does not beat regularly, blood in the heart can pool and clots can form. These clots can travel from the heart through the blood-stream and get lodged in an artery in the brain, causing a stroke or transient isch-emic attack (TIA). A TIA is like a stroke except that the symptoms are short-lived and there is no permanent damage. Peo-ple with AF have a stroke risk of 4.5 per cent per year, but medication that helps to prevent clots, called anticoagulation therapy, can reduce this risk to 1.4 per cent. However, you can take anticoagu-lation therapy to help prevent a stroke only if you know you have AF. And di-agnosing AF is trickier than you might

think. This is because AF often has no symptoms and many people alternate between a normal heart rhythm and the abnormal heart rhythm of AF. Roughly 30 to 40 per cent of first-time strokes are due to an unknown cause, and many of these

may have been caused by undiagnosed, or occult, AF.

Once you have experienced a stroke or TIA, determining whether you have AF can be important to help prevent future strokes – but as we know, diagnosing AF isn’t always easy. Long-term continuous electrocardiography (ECG) monitoring using devices after you are discharged from hospital can help to identify occult AF that is undetectable by other means. There are a number of devices that can be used for outpatient monitoring, includ-ing ambulatory Holter monitors, external loop recorders (ELRs), implantable loop recorders (ILRs), and mobile cardiac out-patient telemetry (MCOT) devices. Am-bulatory Holter monitors typically have three to eight leads connected to your chest, and a small monitor that is carried in a pouch around your neck or waist. Data from the monitor’s continuous re-cordings are stored, then transmitted over the Internet. ELRs use chest electrodes or a wristband to continuously monitor your cardiac activity.

The information is transmitted to a physician or data centre via telephone. ILRs operate similarly to ELRs but are im-planted beneath the skin through a small incision and can remain there for up to three years. MCOT devices use three or four electrodes to monitor cardiac activity. The information is sent to your cellphone, then sent in real time to a data centre.

Currently the use of these outpatient cardiac monitoring devices varies across

Canada. The healthcare community is uncertain how well these devices work to identify occult AF in people who have experienced a stroke or TIA and whether their use offers good value for the costs to the healthcare system. To try and an-swer these questions and to determine how best to use these outpatient cardiac monitoring devices, the healthcare com-munity turned to CADTH – an indepen-dent agency that finds, assesses, and sum-marizes the research on drugs, medical devices, tests, and procedures – to find out what the evidence says. CADTH gathered the evidence from medical research and compared the different monitoring de-vices to determine their clinical and cost-effectiveness for diagnosing AF in outpa-tients who have experienced a stroke or TIA. CADTH also identified patient per-spectives on the value and impact of the AF monitoring devices on their health, healthcare, and quality of life.

In general, the results show that there is a substantial increase in the number of AF diagnoses when monitoring for longer than 24 hours. In other words – the lon-ger you monitor, the more likely you are to detect AF. The results also show that cardiac monitoring after stroke or TIA for the investigation of AF can be cost-effec-tive. Most patients, according to research, perceive outpatient cardiac monitoring devices to be comfortable and easy to use, and satisfaction with outpatient cardiac monitoring is high.

Based on the evidence found by CADTH, an expert panel made recom-mendations on how best to use the out-patient cardiac monitoring devices. The panel recommends monitoring patients who have been discharged from hospital after a stroke or TIA continuously for seven days with either a Holter monitor or ELR. However, if patients have al-ready been monitored while in hospital, outpatient monitoring may not be cost-effective. The panel does not recommend ILRs because they are not cost-effective and from a practical point of view would not make a lot of sense for only seven days of monitoring. A recommendation on MCOT devices isn’t possible because there is very little evidence available for this device.

Knowing the evidence on the use of outpatient cardiac monitoring devices in patients who have experienced a stroke or TIA will help to guide important decisions by patients and their healthcare teams – helping to reduce the risk of future strokes and making the best use of our health care dollars.

If you’d like to learn more about CADTH and our project on monitor-ing for atrial fibrillation after stroke visit www.cadth.ca, follow us on Twitter: @CADTH_ACMTS, or talk to our Liaison Officer in your region: www.cadth.ca/con-tact-us/liaison-officers. nH

Dr. Janice Mann, Bsc, MD is a Knowledge Mobilization Officer at CADTH.

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Preventing another stroke

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Long-term continuous electrocardiography (ECG) monitoring using devices after you are discharged from hospital can help to identify occult AF that is undetectable by other means.

with outpatient cardiac monitoringBy Dr. Janice Mann

062516_HN_EDIT.indd 18 2016-07-05 2:17 PM


19 Nursing Pulse

lizabeth is a 74-year-old patient on the orthopaedic ward. She was admitted to the hospital for a fractured hip. She is quite

uncomfortable and doesn’t want to get out of bed. As a healthcare professional, you are anxious to prevent wounds from form-ing on pressure points on Elizabeth’s body, but every time you try to reposition her, she cries out in pain and doesn’t want to be moved. She says you don’t understand her pain. She eats some of her meals, but has lost her appetite and prefers tea and toast. In the week since her surgery, Eliza-beth has only been out of bed twice, and you notice that her buttock is red.

You determine it is likely a pressure in-jury (formally known as a pressure ulcer), and begin to think about next steps. What is the extent of the injury? What can you do to reposition Elizabeth and prevent ad-ditional pressure injuries? What dressings are best for her buttock? How can you en-courage her to eat more nutritious foods to help improve the healing process?

Pressure injuries are a complex phenom-enon. In general terms, they refer to dam-age to the skin or underlying tissue as a result of sustained pressure. And they have a profoundly negative impact on a person’s physical, social, psychological and financial quality of life. According to the Canadian Institute for Health Information (CIHI), pressure injury rates range from 0.4 to 14.1 per cent, which means many people are af-fected by these injuries in Canada.

In ideal circumstances, wound care is best informed by evidence-based best prac-tices and managed by an interprofessional wound care team. In Elizabeth’s case, it is important to collaborate with Elizabeth, her family, her nurses, physician or nurse practitioner, a physical therapist, occupa-tional therapist, and dietitian to manage her injury.

The Registered Nurses’ Association of Ontario (RNAO) first published its clinical best practice guideline (BPG) Assessment and Management of Stage I to IV Pressure Ulcers in 2007. This spring, a third edition was released under a new name: Assess-ment and Management of Pressure Injuries for the Interprofessional Team. It contains best practice recommendations for pres-sure injury care, with three new features. In addition to replacing the word “ulcer” with “injury,” it now recognizes: the role of various healthcare professionals on a team in the assessment and management of pressure injuries; and the importance of collaborating with the person and their circle of care to better manage the injury.

The panel behind this updated RNAO BPG includes enterostomal therapy nurs-

es, registered nurses, a nursing student, a registered practical nurse, nurse practitio-ners, a physical therapist, a dietitian, an occupational therapist, a physician, educa-tors and researchers. A patient represen-tative was also invited to sit on the panel to provide a lay person’s experience. This patient perspective was important in en-suring that a person-centred approach to the recommendations was applied during the guideline development process.

The guideline recommends best prac-

tices for identifying and treating the causes of pressure injuries, determining the heal-ability of a wound, and wound care treat-ments such as debridement (removal of dead tissue from the wound), controlling inflammation/infection, moisture balance, and the use of alternative approaches for injuries that are not responding to stan-dard wound care.

To learn more about the BPG, contact Grace Suva, RNAO BPG program manag-er ([email protected]), or Erica D’Souza,

project co-ordinator ([email protected]). You can also access an electronic copy of the BPG for free at RNAO.ca/bpg/guidelines/pressure-injuries nH

Grace Suva is a program manager for the International Affairs and Best Practice Guidelines Program at RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario.

Treatment of pressure injuries made clearer with recommendationsBy Grace Suva

E

According to the Canadian Institute for Health Information (CIHI), pressure injury rates range from 0.4 per cent to 14.1 per cent, which means many people are affected by these injuries in Canada.

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062516_HN_EDIT.indd 19 2016-07-05 2:17 PM


20 Long Term Care

urnishings covered with wo-ven upholstery or vinyl with unsealed seams are an infec-tion control hazard.

IC+™ Upholstery Solution is a pat-ent-pending breakthrough technology developed by healtHcentric™ (a divi-sion of ergoCentric®) for the healthcare industry. It provides the most durable, cleanable and impermeable medical-grade surface available. Pathogens, flu-ids, and bed-bugs stay out because IC+ is non-porous, seamless and forms a completely sealed moisture-free barrier that makes microbial growth virtually non-existent.

Creating a home-like environment in Long Term Care (LTC) facilities is im-portant in order to make residents feel comfortable, because whether it’s for a long or short time, it is their home. Home-like environments often include carpeting and plush upholstered couches and chairs. On one hand these provide a sense of comfort, warmth and acoustic value. On the other hand, they can en-able the spread of infectious diseases.

Often used in common areas through-out LTCs for residents, guests and staff to sit on, upholstered couches and chairs can be exposed to various spills and bodily fluids on a daily basis. Woven fabrics naturally lend themselves to cre-ate opportunities for microbial growth as well as odour issues. Instead of creat-ing a nice place to relax, these furnish-ings have the potential to harbour mi-croorganisms and even bedbugs. They are also difficult to clean and when, for example, a cloth chair becomes soaked in feces from a patient infected with C-Difficile, the item needs to be discarded.

Striking a balanceKeith Sopha, President of the Ca-

nadian Association of Environmental Management and the Founder of Clean-Learning says, “I believe, that the LTC sector needs to find a balance between a comfortable home environment and an environment that promotes infection prevention and patient safety.” This can only be achieved by introducing furnish-ings that are cleanable and stand up to hospital grade disinfectants.

The Provincial Infectious Advisory Committee (PIDAC) in the Best Prac-tices for Environmental Cleaning for the Prevention and Control of Infection in all Health Care Settings states “If you can’t clean it don’t buy it.”

LTC facilities are considered health-care settings and have a high risk of in-fectious diseases spreading as residents often share rooms and communal ar-eas. Plus LTC residents generally have a higher risk of acquiring an infection because elderly are more vulnerable to illness.

Pikac ChecklistTo reduce microbial contamination,

when selecting furnishings for use in clinical and communal areas choose sur-faces with the following characteristics:• Cleanable with hospital grade cleaners• Easy to maintain and repair• Resistant to microbial growth

• Non-porous (smooth) and seamlessSopha adds “Furnishings using IC+

have all the characteristics Environ-mental Managers look for. It allows staff to effectively clean and disinfect furni-ture, thus assisting in infection preven-tion and control.”

Proven resultsAn independent study to test the effi-

cacy of IC+ was conducted at Antimicro-bial Test Laboratories. The lab tested the effectiveness of a common isopropanol disinfecting wipe, Cavi Wipes, on a piece of seamed hospital grade vinyl and a piece

of seamless IC+ to compare the reduction of microorganisms on the upholstery sam-ples. The microorganism selected for this test was Staphylococcus aureus, known to be difficult to disinfect but vulnerable to low level disinfectants.

F

recent Supreme Court deci-sion allowing physician-assist-ed death in Canada has ignit-ed a broader national debate

on end-of-life care, including the rights of individuals to determine what kinds of interventions they want or don’t want at the end of their lives. Many Canadian jurisdictions now encourage advance care planning to ensure a more person-centred approach to end-of-life care.

In long-term care, advance directives allow individuals and their families/legal guardians to communicate preferences for interventions and treatments in the event that these individuals are no longer able to make decisions for them.

CIHI’s recent study, A Snapshot of Ad-vance Directives in Long-Term Care: How Often Is “Do Not” Done?, examines how often do-not-hospitalize (DNH) and do-not-resuscitate (DNR) directives were re-corded for residents in 982 reporting Ca-nadian long-term care facilities between 2009–2010 and 2011–2012 and, to the extent possible, whether these directives were followed in acute care settings.

The findings of this study will shed light on how end-of-life preferences of long-term care residents are upheld and communicated across the continuum of care.

How often is a DNR directive followed?

More than three-quarters of long-term care residents in the study had a directive to not resuscitate. A DNR directive states that no cardiopulmo-nary resuscitation (CPR) or other life-saving methods are to be used in the event of cardiac arrest or respiratory failure.

Over the study period, less than 0.05 per cent of residents with a DNR direc-tive received resuscitation in an acute care hospital after being transferred there for treatment. This number repre-sents about one in 2,500 long-term care residents with a DNR directive.

This suggests that do-not-resuscitate orders are well communicated between care facilities and well understood by care providers.

How often is a DNH directive followed?

About one in five long-term care resi-dents (21 per cent) had a documented DNH directive. This type of directive states that the resident is not to be hospitalized even if he or she acquires a medical condition requiring hospital care.

It is important to note that a DNH directive comes into effect only if the resident is unable to provide informed consent at the time of a decision to hos-pitalize or if a family member or legal guardian is unavailable to consult about treatment options.

Almost 6,000 hospitalizations oc-curred among residents with a recorded DNH directive over the three-year study period. This represents almost seven per cent of long-term care residents with a DNH directive. More than half of these cases involved residents who were mod-erately to severely cognitively impaired (or who likely could not make decisions for themselves).

Advance directives in long-term care

A



If you can’t clean it, don’t buy it.Improving infection prevention and control in Long Term Care facilities

Product Feature: IC+™ Upholstery Solution

062516_HN_EDIT.indd 20 2016-07-05 2:17 PM



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bhorrence of the vacuum left following the Supreme Court of Canada’s (SCC) 2015 decision in Carter v. Canada on medi-

cal assistance in dying finally prompted the federal government to introduce Bill C-14 to fill the legislative void. The bill received royal assent Friday, June 17th after passing a final vote in the Senate earlier in the day, despite the Senate’s desire to see a broader scope for medical assistance in dying. How-ever, the timid approach of the Bill to the most contentious aspects of the issue – ad-vance directives, mental health conditions and minors – disappoints in comparison to well-reasoned recommendations that the Special Joint House of Commons-Senate Committee (Committee) tabled in its re-port released in February of this year. The Bill deviates substantially from the Com-mittee’s recommendations, adopting a far narrower and more conservative approach. While the Bill provides a national frame-work for assisted dying, individual prov-inces may, as Quebec has, pass provincial legislation which flesh out some of the sa-lient details around the delivery of these services.

What follows is a brief synopsis of Bill C-14 with respect to eligibility and process. Note that the Bill permits assisted dying services to be provided by both medical practitioners and nurse practitioners, so the language has shifted from ‘physician-assisted’ to ‘medically-assisted’ dying. 1) Bill C-14 Eligibility Criteria for Medi-

cal Assistance in Dying (“MAID”)a) Conditions and Suffering: As ex-

pected, the Bill’s amendments to the Criminal Code do not attempt to statu-torily define specific medical conditions which would be eligible for MAID. Rather, a person is eligible for MAID if s/he has a “grievous and irremedi-able” medical condition which must be: (a) serious and incurable, (b) in an advanced state of irreversible decline in capability, (c) causing enduring physical or psychological suffering, and (d) natu-ral death has become reasonably fore-seeable. This language is substantially more restrictive than Carter; the re-quirement that the individual’s natural death has become reasonably foresee-able would arguably preclude obtaining MAID where a mental health issue is the sole underlying medical condition. However, notably the Bill does not re-quire that the individual has been given a specific survival window, which allows patients and practitioners more latitude around the timing of the assistance.

b) Age: Individuals under 18 years of age are not eligible for MAID. This ap-proach deviates from the Committee’s recommendation that a two-stage legis-lative process dealing first with compe-tent adults and then applying to ‘com-petent mature minors’ to be in force within the following three years.

c) Express Consent and Residency Re-quirements: in addition to meeting the medical condition threshold, an indi-vidual must both be given an opportu-nity to withdraw the request and must provide express consent at the time the assistance is delivered. A request can be made, and witnessed, in writing after the person’s medical or nurse practitio-

ner has informed the person that his or her “natural death has become reason-ably foreseeable”. However, once com-petency is lost MAID may not be pro-vided due to the individual’s inability to provide express consent. For many in-dividuals, the loss of competency might be the trigger for wanting to avail them-selves of MAID, but the above express consent requirement would seemingly preclude this option. In terms of resi-dency, MAID would only be available to persons eligible for publically funded health care services in Canada.

2) The Process involved in requesting MAID

The Bill requires a written request docu-menting a person’s application for MAID, signed and dated by the individual or, if the individual is unable to sign, singed by someone on behalf of the individual and witnessed by two independent people hav-ing no conflict of interest.a) Participating in MAID: Hospitals,

medical and nurse practitioners are not required to provide MAID under Bill C-14, and no provisions are included in the Bill requiring that health care professionals who conscientiously ob-ject to MAID make an effective refer-ral to another medical or nurse prac-titioner as was recommended by the Committee. However, the Bill prohibits the destruction of a document request-ing MAID if the intent is to interfere with access to, or the assessment of a request for, MAID. Medical and nurse practitioners must provide the request to the Minister of Health or his or her designate.

b) Assessments: Two independent medi-cal practitioners or nurse practitioners are required to determine that an indi-vidual meets the eligibility criteria for MAID to be carried out. The second practitioner’s opinion, which confirms that all of the criteria are met, is re-quired to be in writing.

c) Waiting or reflection period: A 15-day waiting period between the request and the delivery of assistance is required, unless both opining medical or nurse practitioners agree that death or loss of capacity to provide informed consent is imminent.

What does this mean for hospitals?

Hospitals providing MAID services should establish internal policies and pro-tocols, including forms and educational documents for patients, to support the medical and nurse practitioners, pharma-cists and other staff who deliver, or assist in delivering, these services to eligible patients. This approach should include an oversight function to address organi-zational accountability for the assessment and administration of MAID.

The Quebec legislation (Bill 52 - An Act respecting end of Life Care) provides an interesting and instructive approach to an institutional framework for assisted dying. For example, Quebec’s legislation requires that hospitals include a clinical program for end of life care in its organi-zational plan, which must include in-home care for end-of-life patients.

Medically-assisted dying:

By Patricia North, LL.B., LL.M.

A

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Residents with a DNH directive were about half as likely to be hospitalized as those without one. The hospitalization rate of residents without a DNH directive was 15 per cent. However, hospitaliza-tion for both groups of residents declined by about half between 2009–2010 and 2011–2012. This coincides with a push in Ontario’s long-term care sector to reduce avoidable hospitalizations.

Why are residents with a DNH directive hospitalized?

The top 10 causes of hospital stays listed below were responsible for nearly 60 per cent of all hospital admissions, including:• Trauma or injury, such as a broken hip

sustained in a fall• End-of-life or palliative care• Infections such as pneumonia, urinary

tract infections and sepsis (infection of the blood stream)

• Exacerbation of chronic conditions such

as heart failure and chronic obstructive pulmonary disease (COPD).

Conclusions Advance care planning or advance di-

rectives are associated with better patient experience and lower costs for the health system.

While long-term care facilities in Can-ada typically discuss care goals with resi-dents, little information is currently avail-able to understand what kind of directives are in place, and whether documented patient preferences are being followed in clinical practice and across the continuum of care.

CIHI’s analysis helps shed light on the use of do-not-hospitalize and do-not-resuscitate directives in long-term care, based on the largest sample of any Cana-dian study on the topic. nHThis article was submitted by the Canadian Institute for Health Information.

The samples were infected with the bacterial culture spread over one square inch and into the seams, where applicable.

After a drying time of 45 minutes, test samples were cleaned using the wipes according to the manufacturer’s instruc-tions, allowed to dry for three minutes, and were then ready for a bacterial count. The lab established that the cleaning and disinfecting wipe had a 0.4 log reduc-tion from the healthcare grade vinyl and a 3 log reduction from IC+ Upholstery Solution. These fi ndings reinforce the recommendation put forth by PIDAC and other reputable organizations that seams in healthcare furniture can har-bor pathogens even after being cleaned and disinfected.

Additional applicationsThe use of IC+ Upholstery Solution

is limitless and healtHcentric is expand-

ing its application to other high-touch products that require extraordinary dura-bility and cleanability. One such product is a commode with an IC+ seat cushion that is much softer than plastic seats and much more durable and cleanable than vinyl seat cushions. And because of the anti-slip nature of the product, healtHcentric is also developing IC+ for transport wheelchairs.

Where to fi nd IC & Upholstery Solution

IC+ is used in hospitals across Canada and the United States. Ontario hospi-tals and LTC facilities receiving funding from the Ontario Government are able to take advantage of the Ontario Public Services Vendor of Record Contract with ergoCentric (healtHcentric’s parent com-pany). Product and sales representation information can be found at www.health-centric.com. nH

Continued from page 20Infection prevention and control

Continued from page 20Advanced directives in long-term care

Total DNH hospital stays 5,783 Pelvic/hip/femur trauma/repair 909 15,7% Viral/bacterial/unspecifi ed pneumonia 460 8.0% Palliative care 350 6.1% Urinary tract infections 300 5.2% Gastrointestinal hemorrage/obstruction 270 4.7% Chronic obstructive pulmonary disease 288 3.9% Other trauma/injury/complication 225 3.9% Sepsis 219 3.8% Aspiration pneumonia 218 3.8% Heart failure without intervention 216 3.7%

Most responsible diagnosis*

Number of cases Percentage

of total cases

Note: *BAsed on modifi ed CIHI Case Mix Groups.Source: Discharge Abstract Database, 2009-2010 to 2011-2012, Canadian Institute for Health Information

Top 10 causes of hospital stays among long-term care residents with a DNH directiveTable 1

To advertise please contact

Denise [email protected]

905-532-2600 ext. 2237

Quebec hospitals must adopt a policy with respect to end-of-life care and make the policy known to personnel and pa-tients, and must also establish measures to promote multidisciplinary cooperation among the different health or social ser-vices professionals. Hospital leadership must report annually to the board of direc-tors on the implementation of the policy, and the report must contain the number of end-of-life patients who received pallia-tive care, the number of terminal palliative sedations administrated, the number of re-

quests for medical aid in dying the num-ber of times this aid was administered, the number of times refused and the reasons for the refusals.

Preparing for the passage of Bill C-14 has been an iterative process for most hospitals, and as new issues or challenges arise, fl exibility and support for the pa-tients and staff involved will continue to be paramount. nH

Patricia North, LL.B., LL.M. is Legal Counsel, University Health Network.

Continued from page 22Medically-assisted dying

062516_HN_EDIT.indd 23 2016-07-05 2:17 PM



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