Objectives: In the emergency department (ED), procedural sedation is commonly performed to facilitate painless reduction of orthopedic injuries. However, this requires intravenous (IV) insertion which is rated by children as the most painful experience in hospital, second only to the presenting condition. In children, IV placement can be very difficult due to small, fragile, and poorly visible veins. In addition, more than 80% children care cared for in community hospitals where nurses have less experience placing IVs. Our trial seeks to find a less invasive approach to IV placement for sedation. This will create a less distressing healthcare experience for families and empower nurses and clinicians to provide care in community settings. It will also reduce institutional and family costs involved in transferring an injured child. Our objective is to determine if an intranasal (IN) combination of ketamine and dexmedetomidine (“Ketodex”) is non-inferior to the standard of care (IV ketamine) for procedural sedation in children. Additional outcomes include duration, onset, and degree of sedation, length of stay, patient and provider satisfaction, adverse effects, and cost. These measures of success directly relate to the ability of Ketodex to be translated into practice.

Innovation: IN Ketodex combines ketamine (analgesia) and dexmedetomidine (sedation). Both agents are widely available across Canadian tertiary care and community hospitals. IN drug administration and monitoring fall within the purview of nurses as regulated health professionals. Unlike IV insertion, minimal skills are required.

Potential for Spread: Knowledge translation (KT) activities supported by the national KT network, Solutions for Kids in Pain (SKIP) are targeted to nurses, child life specialists, clinicians, and policy makers to enhance potential for spread. 7 peer-reviewed manuscripts have been published in open-access journals detailing the methods and analyses to enable researchers and policy makers to replicate our work and apply it to other painful procedures in their institutions. Grand Rounds presentations at 6 paediatric centres and 8 professional development webinars targeted clinicians and nurses. Finally, a recently completed a qualitative study of paediatric ED nurses suggesting an overall positive impression of IN sedation with respect to administration, benefit for the child, and resource use, together with our pilot work and systematic reviews informed a practice parameter for the safe and effective use of IN sedatives than can be easily adopted by ED nurses across Canada. It was ratified by nursing professional practice and disseminated to 6 Canadian paediatric EDs. Future KT activities include a peer-reviewed manuscript of the main findings, two podcasts (Skeptics Guide to Emergency Medicine; EMRap), a “Bottom Line Recommendation” from Translational Emergency Knowledge for Kids (TREKK), infographics posted on social media, and presentation at 3 national conferences to target community EDs.

Beyond the Innovation Fund: The study secured additional funding from the Canadian Institutes for Health Research, the Physicians Services Incorporated, and the Province of Ontario Early Researcher Award to allow completion of the trial given the numerous pandemic-related personnel and drug shortages. Our practice parameter has been adopted by the Children’s Hospital ED, LHSC and 5 other Canadian paediatric EDs. Upon completion of KT activities, clinical informatics data and root cause analyses will be used to gauge uptake and identify barriers and facilitators to adoption, respectively.

Objectives: Kidney transplantation is currently the best treatment option available for patients with kidney failure. Unfortunately, the need for kidneys is greater than the number of acceptable donors available. To increase access to transplantation, organs from higher risk donors are being used more frequently, though this results in greater risk of poor outcomes for patient post-transplant. Currently, donor organs are stored on ice until the time of transplant, during which the kidney suffers injury from the cold temperatures and lack of oxygen. Research from our group suggests that providing oxygen to pig kidneys at around room temperature can reduce injury, protect kidneys from inflammation, and improve their function. Therefore, we aim to establish new normothermic and subnormothermic ex vivo pulsatile perfusion-reperfusion method for preserving donor kidneys ex vivo. Our objective is to investigate strategies for reducing pre-transplant injury and maintaining optimal organ function post-transplant, namely by assessing the impact of preservation temperature and the addition of repositioned drugs during reperfusion.

Innovation: We have successfully developed a donor kidney porcine model by clamping the renal pedicles in situ to mimic clinical warm ischemia or donation after circulatory death (DCD) conditions. Since we are investigating a novel way of preserving and protecting donor kidneys, which deviates away from the current stadard-of-care, we have extensively studied its superiority in our porcine model prior to human study; we have optimized numerous factors including perfusate composition, temperature, pressures, type of pump, nutritional supplementation and oxygenation. The innovation has enabled us to submit for a patent application (pending) for this method. In addition, we have successfully re-modelled a renal perfusion-reperfusion pump-cassette system by adapting an existing hypothermic pump and incorporating into it an oxygenator, leukocyte depletion filters, and deoxygenated blood route suitable for adding drugs and gasotransmitters externally. This pump-cassette system has also been submitted to Health Canada for commercial use approval as a Class II clinical equipment. With the help of AMOSO funding, we have made several important conclusions, including demonstrating superior preservation of donor kidneys at 22^°C for prolonged ex vivo storage. The AMOSO grant was instrumental for translating this outcome into our upcoming human pilot study at our Centre.

Potential for spread:  Unlike the standard cold preservation technique, this novel system will perfuse blood  or  blood products  under flexible conditions (e.g. temperature and pressure), which can be made identical to in vivo renal fluid dynamics. The main idea of this proposal was to develop a working system where the efficacy of existing drugs can be tested in human organs so that successful candidates can be brought into the clinic without having additional regulatory approval. By developing an effective method to extend the life of DCD kidneys, we aim to improve transplant surgery outcomes, enhance patient quality of life, and decrease healthcare costs globally. Most importantly, once optimized, this system has the potential to serve as a testing environment for other organs, which would position us at the forefront of organ transportaion as well as preservation research.

Beyond the Innovation Fund: The AMOSO project has generated exciting new knowledge and enough preliminary data from which we have secured multiple grants, including CIHR. Our work has received citations world-wide and is recognized by renowned journals. As such, the AMOSO innovation fund has potentiated significant advancement in transplantation research.

Objectives: Studies have shown that receiving palliative care early increases quality of life in patients with advanced cancer, but most patients do not have timely access to outpatient palliative care. We developed a new way to identify patients with the greatest need for palliative care (i.e., those with severe symptoms) for triage by a nurse and referral to a palliative care clinic (PCC). This system, called STEP (Symptom screening with Targeted Early Palliative care), uses information patients routinely report about their symptoms electronically before each oncology clinic appointment to target palliative care to outpatients who need it. We conducted a pilot trial of STEP with feasibility criteria including accrual of at least 100 patients in 12 months, completion of at least 70% of symptom screens for at least 70% of visits, and at least 60% of screen-positive patients meeting with the palliative care team.

Innovation: Symptoms were screened at every outpatient oncology clinic visit using the Edmonton Symptom Assessment System-revised (ESAS-r) for 116 patients attending the Princess Margaret Cancer Centre (PM) between 11/2016 and 1/2018. Moderate to severe symptom scores (≥4/10 for pain, nausea, dyspnea, depression, anxiety; ≥7/10 for fatigue, appetite, drowsiness, well-being) triggered an e-mail to a nurse, who then called the patient to offer a PCC visit. STEP was found to be feasible according to the above criteria; further, those screening positive who were subsequently seen at the PCC had improved symptom control and mood. While there have been widespread calls internationally for symptom screening to triage palliative care services, this is the first formal trial to demonstrate the feasibility and preliminary efficacy of this approach; moreover, STEP is transferable to other cancer centres in Ontario and worldwide.

Potential for spread: Since symptom screening is mandated by Cancer Care Ontario at all provincial cancer centres, and all of these centres provide access to outpatient palliative care, STEP is transferable to all Ontario cancer centres. As well, international cancer guidelines recommend both routine symptom screening and early access to outpatient palliative cancer care; thus our trial supports and provides evidence for these international recommendations. Preliminary results of this trial were presented at the American Society of Clinical Oncology meeting in Chicago in 2019, and full results were subsequently published in the Journal of the National Comprehensive Cancer Network (Zimmermann et al., Phase II Trial of Symptom Screening with Targeted Early Palliative Care for Patients with Advanced Cancer. JNCCN 2021; 20(4):361-370).

Beyond the Innovation Fund: We successfully secured funding from the Canadian Institutes of Health Research (>1M CAD) to conduct a large multicentre randomized controlled trial of STEP versus usual cancer care.

Traditional neuraxial anesthesia techniques, which rely on anatomical landmarks and operator’s memory of ultrasound images, often poorly account for anatomical variability and can lead to inefficient procedures with increased complications. We have developed an ultrasound-based guidance system, which displays a holographic projection of the ideal needle path in the user’s field of view using the Microsoft HoloLens augmented reality headset.

This technology was first piloted using a lumbar phantom model and then directly compared to traditional techniques in a randomized controlled trial of epidural insertion. Eighty-four patients were enrolled in the trial. The primary outcome of procedure time was significantly reduced in the HoloLens group relative to control (7.3min vs. 4.5min), as was the number of needle movements required (14.4 vs 7.2). There was no significant difference in intra- or post-procedure pain, bone contacts, or total number of needle punctures. Notably, while not significant, epidural administration failed in 3 participants in the control group, compared to 0 participants in the HoloLens group. Thus, this innovative, accessible technology has the potential to reduce patient morbidity and increase procedural efficiency, although further studies are needed to confirm improved patient outcomes.

A peer reviewed manuscript detailed the development and usability testing of this technology has been published. As well, a peer-reviewed manuscript detailing the results of the randomized control trial is currently in preparation, with plans to implement HoloLens at Sunnybrook, before potentially expanding to other institutions and patient populations. Also, it can be used as a teaching and clinical tool, especially for health care providers and patients in remote and rural communities. To aid wider adoption, we plan to make freely available all the software code and resources needed to replicate and adopt our novel technique.

Objectives:  Sepsis is one of the top causes of death in Canada, and timely initiation of effective antibiotic treatment is the most important way to increase survival among these patients. However, as antimicrobial resistance rates rise among our most common bacterial pathogens, choosing the right empiric antibiotic treatments becomes increasingly difficult and more likely to result in inadequate coverage for patients. Our team has previously demonstrated that readily available patient risk factors can accurately predict the likelihood of antibiotic resistance in the bacteria causing their infections; yet, clinicians are not incorporating these factors into decision making. The overarching objective of this research program is to increase timeliness of adequate empiric antibiotic treatment by individualizing treatment recommendations for patients based on their risk factors for resistance.

Innovation:In the Improving Decision-Making for Empiric Antibiotic Selection (IDEAS) Study we used early audit-and-feedback to warn clinicians when their antibiotic selections may not be effective against the infecting bacteria. Our intervention successfully improved the time to adequate antibiotic coverage for patients with sepsis, while at the same time reducing overall use of broad-spectrum antibiotics.  Usually these are conflicting goals, but by individualizing treatment recommendations our innovative approach is able to both improve adequate coverage for patients and antimicrobial stewardship (ASP).

Potential for Spread:  ASP is a required organizational practice, and so the IDEAS intervention could be implemented by existing ASP teams at any acute care hospital across Ontario (or Canada).  The intervention is designed so that once safety and efficacy is confirmed it can be transformed into electronic decision support to facilitate sustainable dissemination through hospital electronic medical records.

Beyond the Innovation Fund:  The IDEAS results are published in two high impact manuscripts in Clinical Infectious Diseases (https://pubmed.ncbi.nlm.nih.gov/32930719/; https://pubmed.ncbi.nlm.nih.gov/32640028/), and have garnered multiple awards for innovation in ASP, including the Canadian Society of Hospital Pharmacy (CSHP) Patient Care Award (January 2021) and the Canadian Society of Hospital Pharmacy Ontario Branch Bill Wilson Patient Safety Award (September 2020).  We have leveraged the success of IDEAS, to obtain a Canadian Institutes of Health Research (CIHR) Spring 2022 Project Grant Award for IDEAS II: A Cluster Randomized Cross-over Trial of an Antibiotic Decision Support Intervention in Sepsis.  This CIHR award will help us to expand the IDEAS approach to an earlier window of sepsis when patients first arrive at hospital in order to maximize impact; the funds will also extend the study from Sunnybrook to include the Ottawa Hospital and Trillium Health Partners.  The next step following IDEAS II will be to incorporate our intervention into electronic decision support and disseminate across Ontario and beyond.

Objectives: Emergency department visits and readmissions post-surgical discharge are high (10-20%). This may reflect the fact that, when discharged home, patients are no longer monitored, care largely relies on family members, and access to health care is limited. In order to address this issue we created the Virtual Recovery After Surgery program at The Ottawa Hospital.

Patients in the program are taught how to use innovative virtual care technology to use take daily surgical recovery monitoring surveys and transmit vitals to a virtual nurse (up to one month following surgery). Nurses regularly meet with patients to review their health, reinforce best practices for recovery, and undertake medication reviews. Any issues are escalated to a physician on call for the service. IFPOC funding allowed us to measure the impact of this service in a randomized control trial. We found that services led to high patient satisfaction and improved pain control ( a frequent cause of readmissions). Moreover, our high intensity service (i.e. checking in on patients and escalating care) was associated with decreased acute care visits.

Innovation:  Few programs exist worldwide for virtual recovery after surgery. The trial conducted was the largest one to date and multiple programs were established at participating sites across Canada. IFPOC funding has allowed us to build a virtual recovery program that is being recognized provincially and nationally.

Potential for spread: Given the high-rate of stakeholder buy-in (e.g. surgeons, patients, hospital executive) this technology can be readily transferred to other institutions. Other regional centres have already consulted our group to better understand how to implement a successful program (e.g. Hawkesbury General Hospital). As mentioned above, multiple sites across the country have continued their post-surgical virtual care programs. Several knowledge translation strategies are being employed: 1) Publication – trial results were published in the BMJ (https://doi.org/10.1136/bmj.n2209); 2) Two invited presentations to Ontario Health (2021, 2022). Meetings were attended by ministry leadership and by other centres interested in remote monitoring for surgical transitions in care; 3) Invited presentations in sessions for Innovations in Perioperative Care by the Canadian Anesthesiologists’ Society (national meeting 2022); 3)Continued stakeholder engagement and program improvement through Plan-Do-Study-Act cycles (funded by a TOHAMO Quality Improvement Grant 2022).

Beyond the Innovation Fund: Based on the promising results of the trial, we successfully received program funding from the Ontario Health Remote Care Management/Surgical Transitions Remote Care Monitoring for two cycles (2021-2022, 2022-2023). This funding has paid for nursing staff as well as a project manager. We are currently working with Dr. Jack Kitts (former CEO of The Ottawa Hospital) and other leadership to develop a long-term sustainability plan.

Objectives: We developed the Canadian Syncope Pathway (CSP) based on the Canadian Syncope Risk Score (CSRS) to aid disposition decision-making for emergency department (ED) syncope. This pilot implementation study assessed feasibility of patient inclusion, length of transition period, as well as process measures (engagement, reach, adoption, and fidelity) to prepare for multicenter implementation.

Methods: A non-randomized stepped wedge trial at two (one academic and one community) hospitals was conducted over a 7-month period. After 2 – 3 months in the control condition, the hospitals crossed over in a stepwise fashion to the intervention condition for 4 – 5 months. Study participants were ED and non-ED physicians, or their delegates, and patients (aged ≥18 years) with syncope. We aimed to analyze patient characteristics, ED management including disposition decision, and CSRS recommendations application for all eligible patients during the intervention period. Our targets were 95% inclusion rate, 70% adoption, 60% reach and 70% fidelity for all eligible patients. Clinical Trials registration NCT04790058.

Results: 1002 eligible patients (mean age 56.6 years; 51.0% males) were included: 349 patients during the control and 653 patients during the intervention period. Physician engagement varied from 39.7% to 97.1% for presentation at meetings. Process measures for the first month and the end of the intervention were: adoption 70.7% (58/82) and 84.4% (103/122), reach 67.5% (108/160) and 55.0% (359/653), fidelity among patients for whom the physician completed the data form 86.3% (88/102) and 88.3% (294/333), versus fidelity among all eligible patients 83.8% (134/160) and 83.3% (544/653) respectively with no significant differences in fidelity at one month and the end of the intervention period.

Conclusion: In this pilot study, we achieved all prespecified benchmarks for proceeding to the multicenter CSP implementation except reach. Our results indicate a one-month transition period will be adequate though regular reminders will be needed during full-scale implementation.

Innovation: The innovation is the implementation of a complex intervention through robust knowledge translation strategies, exploiting technology – integration of the pathway within electronic health records and use of remote cardiac rhythm monitoring.

Potential for spread: The same implementation strategy can be adopted at other Canadian institutions to improve patient safety and health care efficiency by reducing utilization.

Beyond the Innovation Fund: Yes, we have secured a CIHR grant for $1.25 million for implementation at 16 hospitals across Canada.