Congratulations to our 2018 Award Winners!
We receive many nominations from our participating Governance Organizations, and our reviewers were most impressed with the quality of work being undertaken by our AHSC AFP physicians and their project teams. Again this year, the nominations were grouped into 5 categories, and the winners chosen from among meaningful innovative projects nominated in each group.
Dr. Philippe Bédard
From Mount Sinai – University Health Network Academic Medical Organization for “Community Oncology Molecular Profiling in Advanced Cancers Trial (COMPACT)”
Cancer, Palliative Care, Geriatric, Mental Health and Addiction
Dr. Jerome Leis
From Sunnybrook Medical Services Alternative Funding Plan Association for “Introduction of penicillin skin testing to improve use of beta-lactam therapy among hospitalized patients with reported allergy”
Health System, Quality Improvement and Safety
Dr. Karen Choong and Dr. Douglas Fraser
From the Hamilton Academic Health Sciences Organization (Dr. Choong) and the Academic Medical Organization of Southwestern Ontario (Dr. Fraser) for “Functional Recovery in Critically Ill Children: the “Weecover” longitudinal cohort study”
Award Category: Women and Children
Dr. Dar Dowlatshahi
From The Ottawa Hospital Academic Medical Organization for “RecoverNow: mobile tablet-based stroke rehabilitation in the acute care setting”
e-Health, Technology, Monitoring
Dr. Leah Steinberg
From Mount Sinai – University Health Network Academic Medical Organization for “Advanced Heart Failure Collaborative (HeartFull) Model Initiative to address gaps in providing home-based palliative care to pts with end stage heart failure (ESHF)”
Cardiac, Stroke, Critical Care, Emergency Medicine and Surgery
Community Oncology Molecular Profiling in Advanced Cancers Trial (COMPACT)
Dr. Philippe Bédard
Objectives: The aims of this project were to: 1) provide access to molecular profiling to patients with selected advanced solid tumors; 2) identify patients with genomic alterations who may be candidates for clinical trials with new drug treatments, and; 3) uncover the challenges faced by community oncologists regarding the incorporation of genomic data into clinical care.
Innovation: COMPACT was the first comprehensive molecular cancer screening program in Canada that sought to provide access to state-of-the-art molecular profiling for patients receiving cancer treatment across Ontario, by providing oncologists with specific cancer gene information to help tailor each patient’s treatment. A total 836 patients from 31 Ontario hospitals and 105 community oncologists were enrolled over 3 years. Molecular profiling was successfully completed for 727 patients (87%). Of these, 449 (62%) had one or more mutations identified in their cancers, and 93 (21%) of patients with mutation(s) were subsequently treated in therapeutic clinical trials at Princess Margaret Cancer Centre, including 34 (8%) who received treatment on genotype-matched clinical trials (Stockley et al Genome Medicine 2016). COMPACT broadened the infrastructure for clinical research through greater outreach and education to community oncology centres.
Potential for Spread: As a result of the experience gained through this study, the University Health Network’s Advanced Molecular Diagnostic Laboratory (AMDL) transitioned targeted next generation sequencing (NGS) panels for routine clinical testing of patients with melanoma and colorectal cancers. Clinical and genomic data from the COMPACT were shared with the cancer research community through the first public release of the American Association for Cancer Research Project GENIE initiative (Cerami et al Cancer Discovery 2017).
Beyond the IF: The Ontario Cancer Targeted Nucleic Acid Evaluation (OCTANE) trial (NCT02906943) was recently launched at five academic hospitals across Ontario to enable targeted NGS testing for patients with advanced solid cancers and province- wide data sharing. Funding for this study is provided through the Ontario Institute for Cancer Research (OICR) and the Princess Margaret Cancer Foundation.
Introduction of penicillin skin testing to improve use of beta-lactam therapy among hospitalized patients with reported allergy
Dr. Jerome Leis
Transformation: The penicillin family of antibiotics remains one of the most effective treatments against bacterial infection. Patients who report allergy to penicillin frequently receive second-line antibiotics which may be less effective and carry greater chances of promoting antibiotic resistance. Penicillin skin testing (PST) is a simple, inexpensive and reliable bedside test to exclude the presence of allergy but is currently only available in specialized outpatient clinics. This study’s aim was to introduce PST at the bedside for hospitalized patients with bacterial infections to determine whether the preferred penicillin antibiotic could be safely used.
Innovation: Antimicrobial Stewardship Teams, composed of hospital pharmacists and physicians with a mandate for ensuring patients receive the most appropriate antibiotic when they need it, were trained by Allergists on how to perform and interpret PST. Across three hospitals, PST was offered to any patient with reported allergy to penicillin with a bacterial infection who was unable to receive the preferred penicillin antibiotic due to the severe nature of their reported allergy. After introducing PST, the use of penicillin nearly tripled while alternative agents associated with greater risk of adverse drug reactions, like fluoroquinolones and carbapenems, decreased by over half. No patient suffered a severe reaction to penicillin and the overall rate of adverse events was the same as before introduction of PST.
Potential for Spread: This study demonstrates that PST is a feasible intervention that can be performed by trained hospital pharmacists and physicians. Since Antimicrobial Stewardship Programs are a Required Organizational Practice, this intervention could be scalable across Canadian acute care hospitals. The impact among hospitalized patients with reported allergy could be significant, since 10% of Canadians report an allergy to penicillin. By safely improving the use of penicillin antibiotics, Antimicrobial Stewardship-led PST has the potential to improve treatment outcomes for these patients. Conversely, sparing alternative antibiotic options through PST means that these other antibiotic classes can be reserved for infections that warrant them. PST may therefore be an important strategy for limiting the broader development of antibiotic resistance.
Beyond the IF: PST is now a standard practice offered by Antimicrobial Stewardship Teams across the 3 hospitals that participated in the study. The results were published in Clinical Infectious Diseases, the journal of the Infectious Diseases society of America. The study has raised awareness about the need to improve antibiotic prescribing practices for patients with a reported allergy to penicillin, through media attention that included a special feature on the National. PST is now being introduced across 8 other hospitals in Ontario with funding received from IFPOC in 2018, to undertake a larger study that will be powered to measure the impact on overall patient outcomes.
Functional Recovery in Critically Ill Children: the “Weecover” longitudinal cohort study
Dr. Karen Choong and Dr. Douglas Fraser
Objectives: This prospective cohort study was conducted at the Pediatric Intensive Care Units (PICUs) at McMaster Children’s Hospital and London Health Sciences. We evaluated long-term functional outcomes and quality-of-life (QOL) in critically ill children, and qualitatively determined outcomes deemed most important to patients and families. Key findings from this study that impact on healthcare delivery are firstly, that the majority of children survive critical illness, but with important sequelae that persist post hospital discharge – 82% experience significant functional decline; 67% demonstrate some improvement at 6-months but the majority have a persistent decline in their QOL and are still are functioning below expected for age. Secondly, 61% of children develop preventable PICU-acquired complications (PACs) such as delirium, iatrogenic withdrawal and muscle weakness. The development of PACs and parental stress are significant risk factors for poor functional recovery – PACs are therefore key modifiable targets for improving patient outcomes. Thirdly, once survival is clear, family members prioritize their child’s functioning, QOL, rehabilitation, community supports and caregiver related outcomes.
Innovation: This is the first study to our knowledge to understand survivorship in critically ill children using patient reported outcome measures, and determine risk factors for poor functional outcome. The innovation for the field of pediatrics is as follows: 1) aspects of functioning (i.e. physical, cognitive and social) are affected differently in critical illness, and therefore should be addressed through different rehabilitation strategies; 2) we identified that the risk of PACs may be reduced by decreasing sedative use and the earlier introduction of rehabilitation, subsequently improving duration of hospitalization and functional recovery in critically ill children.
Potential for Spread: These multi-center results are generalizable to critically ill children in other PICUs in Canada, and other developed countries. This project has had significant impact in the field of critical care and pediatric medicine as evidenced by the following:
1) Our findings from this single project have to date generated 3 publications (2 inPediatric Critical Care Medicine, 1 under review).
2) We presented our findings at a national webinar hosted by the Canadian Association of Paediatric Health Centers. I have presented our project findings at key international meetings (Critical Care Canada, American Thoracic Society), and have been invited as a keynote speaker to present our results at the Society of Critical Care Medicine 2018 and the World Congress of Pediatric Critical Care 2018.
Beyond the IF: Our results confirm that the “post-intensive care syndrome” exists in children and are being used to develop strategies to improve survivorship after critical illness. We have determined that functioning and QOL are responsive, patient centered outcomes that should replace mortality as the definitive outcome in PICU research. We have used our results to develop quality improvement bundles of care designed to reduce PACs and ensure patient and family centered care. These bundles have been adopted by our institution, and others in the Canadian ICU Collaborative and Critical Care Strategic clinical network in Alberta. We successfully secured funding for next phase of research, to evaluate the impact of our innovative quality improvement bundle (“PICU Liber8”), on the process of care and functional recovery in critically ill children.
RecoverNow: mobile tablet-based stroke rehabilitation in the acute care setting
Dr. Dar Dowlatshahi
Objectives: Stroke is a leading cause of disability among Canadians. Each year, approximately 62,000 Canadians suffer a stroke. The majority of patients survive and live with the consequences: currently, over 400,000 stroke survivors live in Canada with disability. Only 16% of Canadians with stroke access rehabilitation and, of those, only 50% do so within 2 weeks of their stroke. Patients spend an average of 8 days in acute care awaiting a rehab bed. We see an opportunity for mobile device technologies to help start recovery therapy while patients are still in acute centres.
Innovation: Our RecoverNow concept is the first to “bring rehab to the patient.” Using existing technology, patients start recovery therapy while still in their beds receiving medical treatments for their stroke. Patients in acute-care hospitals spend over 60% of their time lying in bed, inactive and alone. Our innovative concept allows patients to actively engage in recovery activities during this “downtime”, especially their evenings and weekends where there is little in the way of therapy. Furthermore, because our treatment is mobile, the RecoverNow tablet can travel with the patient as they transition from hospital to rehabilitation facilities and home. Throughout this journey, patients maintain contact with their recovery therapists with face-to-face video applications and texting.
Potential for Spread: RecoverNow is adaptable and can be used in any acute care hospital, rehab facility, or outpatient environment (including homes). We are already in negotiations with industry to scale RecoverNow and target different jurisdictions and healthcare stakeholders.
Beyond the IF: We have recently secured peer-reviewed grant funding from the Heart & Stroke Foundation of Canada to conduct a multi-centre clinical trial to prove the efficacy of RecoverNow, and to perform a health economic evaluation. Toronto and Calgary have already joined onto the project, and we have interest from Montreal, Hamilton and Vancouver for the subsequent phase.
Advanced Heart Failure Collaborative (HeartFull) Model Initiative to address gaps in providing home-based palliative care to pts with end stage heart failure (ESHF)
Dr. Leah Steinberg
Objectives: The HeartFull Collaborative addresses the gaps in providing home-based palliative care to patients with end stage heart failure (ESHF). Numerous studies demonstrate that patients with ESHF have a high symptom burden; lack clear communication about end of life care; are unable to access palliative care services and lack access to symptomatic treatments such as parenteral diuresis in the community environment. This gap has led to a call from the major cardiovascular societies to provide palliative care (PC) resources for patients with ESHF.
Our project focused on addressing two specific challenges. First, we developed a curriculum for home-based clinicians (family physicians, NPs, PC specialists). This included development of a home-based diuretic protocol, a tool that guides clinicians in the home-based dosing of diuretics (parenteral and oral), the treatment of common symptoms in ESHF and support around advance care planning in this population.
To address the second challenge, we created an interdisciplinary team for the patient, including a community clinician (MD or NP), the patient’s cardiologist, the CCAC team, and a specialist palliative care clinician. The team was provided with an ability to communicate in real time. This model allowed the team to share knowledge and expertise to support patients in their home, to continue with primary care in the home, and to use palliative care specialists for more complex symptom management as required. And the home based team benefited from real time mentorship and clinical assistance from the cardiologist.
We measured symptom burden, caregiver burden, quality of life, satisfaction with care, utilization and place of death as well as costs to the health care system (both public and private costs). Significantly, we have found no worsening symptoms or decrease in satisfaction or burden scores after transition to a home based care team. In addition, there is a reduction in hospital utilization and patients have been able to die in the location of their choice, often in the home or a palliative care unit.
Innovation: This is an innovative program because before the program, many cardiologists were reluctant to refer to PC as they wanted to stay involved in their patient’s management. We developed innovative teaching and resources for clinicians, improving the care to patients with ESHF. This collaborative allowed the clinician to share knowledge and allows the patient to be cared for in the location of their choice. We have seen a significant increase in the number of referrals to the palliative care team.
Potential for Spread/Beyond the IF: Since the inception of our program, several organizations have asked to learn from our model: (1) The Home-based diuretic protocol is in press in the journal: Canadian Family Physician (2) The Foundation for Medical Practice Education www.fmpe.org published our model for their PBSG CME programs, distributed to over 27,000 family physicians in Canada. We have been invited to teach at several large education events, including the CHPCA Advanced Learning Institute (2014, 2016), the CHPCA accredited webinars, the Peter Munk Cardiovascular Symposium and the Hospice and Palliative Care Association of Ontario conference. We have also been asked to assist the development of similar programs at St. Joseph’s Health Centre, William Osler Health Centre and The Victoria Hospice in Victoria, BC.