Capital District Health Authority Research Articles

Monitoring adverse events in older hospitalized patients: A retrospective cross-sectional study using validated screening criteria with administrative data

Objective: Older patients are at higher risk of experiencing an adverse event (AE) during an acute hospitalization. The objective of the current study was to use routinely collected administrative data to characterize AEs and their system-level impact for older patients hospitalized in one Canadian health authority.Methods: This retrospective cross-sectional study occurred in the Capital District Health Authority in Nova Scotia, Canada between April 1, 2012 and March 31, 2013. The primary outcome was identification of pressure ulcers, fall-related injuries and adverse drug events in patients 65 years of age and older admitted to an acute inpatient service. AEs were identified using validated screening criteria. Data were analyzed using standard descriptive statistics.Results: There were 11,747 hospitalizations during the study period. A total of 330 (2.8%) AEs in 325 patients were identified using the screening criteria. This included 55 (16.7% of 330) pressure ulcers, 25 (7.6%) fall-related injuries and 250 (75.8%) adverse drug events. The average length of stay was significantly higher in patients with a pressure ulcer (35.8 ± 47.3 vs. 9.0 ± 14.8 days, p < .0001), fall-related injury (30.3 ± 23.2 vs. 9.0 ± 15.2 days, p < .0001), or adverse drug event (14.6 ± 14.4 vs. 9.0 ± 15.2 days, p < .0001) during their acute hospitalization.Conclusions:Use of validated screening criteria with administrative hospitalization data provides important information for monitoring the system-level impact of common AEs in older patients. Significant and clinically important differences in healthcare utilization underscore the value in monitoring these AEs in this growing patient population.

Falls and long-term care: a report from the care by design observational cohort study

BackgroundFalls and the resulting complications are common among frail older adults. We aimed to explore risk factors and potential prevention strategies for falls in elderly residents of Long-Term Care Facilities (LTCF).MethodsThis was a cross sectional study design using data from the Care by Design (CBD) study, within Nova Scotia’s Capital District Health Authority. This observational time series cohort study collected data before, during and after the implementation of CBD, a new model of coordinated primary care in LTCF. Here, we analyzed data collected after the implementation of CBD (September 1, 2011- February 28, 2012).ResultsFalls were frequent; 56.2% of our sample of 395 residents fell at least once. In univariate analyses, male gender (p = 0.009), dementia (p = 0.005), and use of Selective Serotonin Reuptake Inhibitors or Selective Serotonin-Norepinepherine Reuptake Inhibitors (SSRI/SNRI) (p = 0.084) showed statistically significant associations with having fallen. Benzodiazepine use appeared to be protective for falls (p = 0.058). In a fully adjusted multivariable linear regression model, dementia (β coefficient 0.96, 95% CI: 0.83,1.84; p = 0.032), visual impairment (β 0.84, 95% CI: 0.13,1.56; p = 0.021), and use of any PIMs (β 0.34, 95% CI: 0.037,0.65; p = 0.028) were associated with increased risk of having fallen. Benzodiazepine use remained associated with reduced numbers of falls (p = 0.009), and SSRI/SNRI use was associated with increased numbers of falls (p = 0.007). Male gender was associated with increased falls in the model which excluded frailty (p = 0.022), though gender lost statistical significance once frailty was added to the model (p = 0.06).ConclusionsIn our sample of LTCF residents, falls were common. Cognitive impairment, male gender, visual impairment, PIM use and use of SSRI/SNRI medications were associated with increased risk of falls, while benzodiazepine use appeared to be associated with a decreased risk of having fallen. Falls remain an important problem among LTC residents. Screening for falls during patient encounters is recommended, along with further research to identify risk factors and target interventions.

Physician leadership development: Evidence-informed design tempered with real-life experience.

This article describes key considerations for creation of evidence-informed in-house physician leadership development. Ten elements extracted from a scan of the peer-reviewed and grey literature are presented, and key learnings at the Queen Elizabeth II Health Sciences Centre, a quaternary academic health sciences centre in Halifax, Nova Scotia, are highlighted. Each element is briefly described with practical considerations and challenges to implementation outlined in the context of the former Capital District Health Authority, where the authors collaborated to create in-house physician leadership development prior to the consolidation of health districts in that province. The purpose of this article is to share how the authors used evidence to plan physician leadership development and to explore the additional situational and contextual factors and considerations needed for implementation.

A universal infant rotavirus vaccine program in two delivery models: Effectiveness and adverse events following immunization

Rotavirus is the most common cause of diarrhea leading to hospitalization in young children. Rotavirus vaccines are available in Canada but have not been introduced in all provinces. In a controlled trial, 2 study sites (Prince Edward Island and the Capital District Health Authority (District 9, Nova Scotia) introduced universal rotavirus vaccine programs for infants at 2 and 4 months of age beginning 1 December 2010, using public health nurse or general practitioner-delivery models, respectively. A third site (Saint John, NB) served as the non-intervention control setting. Vaccine coverage, rotavirus hospitalizations, intussusception and all-cause diarrhea were monitored. A universal rotavirus vaccine program with >90% coverage was associated with reductions in rotavirus-associated hospitalizations (from a peak of 52.8 hospitalizations/100,000 population to 0 hospitalizations) in infants < 12 months and 1 to < 2 y of age 12 months after program implementation. No apparent reduction occurred in the site with vaccine coverage of < 40%, or in the non-intervention control site. No cases of intussusception were associated with vaccine receipt, and no increase in all-cause diarrhea was observed. A universal infant rotavirus vaccine program with high coverage was associated with reductions in rotavirus and no safety signals; no reduction was observed in settings with low vaccine coverage.

Costs and stewardship of laboratory tests in the Capital Health District

Responsible use of diagnostic resources benefits the Canadian healthcare system. Educating clinicians about the costs of laboratory tests can reduce corresponding resource use, both by encouraging substitutions with appro- priate and less-expensive alternatives, and by reducing overall diagnostic workup loads where warranted. To that end, this paper presents the costs of commonly used laboratory tests, and of some less-expensive alternatives, for the Capital District Health Authority of Nova Scotia, Canada. It then compares the aggregate costs of representa- tive brief and elaborate workups for six common patient presentations. When used appropriately, initial workups composed of fewer test alternatives can save between $11.27 (abdominal pain) and $103.63 (shortness of breath) per workup without affecting patient care. Making judicious test substitutions can also provide savings. Clinicians are encouraged to consider these costs and alternatives when providing future patient care.

Novel web-based real-time dashboard to optimize recycling and use of red cell units at a large multi-site transfusion service

Background: Effective blood inventory management reduces outdates of blood products. Multiple strategies have been employed to reduce the rate of red blood cell (RBC) unit outdate. We designed an automated real-time web-based dashboard interfaced with our laboratory information system to effectively recycle red cell units. The objective of our approach is to decrease RBC outdate rates within our transfusion service. Methods: The dashboard was deployed in August 2011 and is accessed by a shortcut that was placed on the desktops of all blood transfusion services computers in the Capital District Health Authority region. It was designed to refresh automatically every 10 min. The dashboard provides all vital information on RBC units, and implemented a color coding scheme to indicate an RBC unit's proximity to expiration. Results: The overall RBC unit outdate rate in the 7 months period following implementation of the dashboard (September 2011-March 2012) was 1.24% (123 units outdated/9763 units received), compared to similar periods in 2010-2011 and 2009-2010: 2.03% (188/9395) and 2.81% (261/9220), respectively. The odds ratio of a RBC unit outdate postdashboard (2011-2012) compared with 2010-2011 was 0.625 (95% confidence interval: 0.497-0.786; P < 0.0001). Conclusion: Our dashboard system is an inexpensive and novel blood inventory management system which was associated with a significant reduction in RBC unit outdate rates at our institution over a period of 7 months. This system, or components of it, could be a useful addition to existing RBC management systems at other institutions.

A new long-term care facilities model in nova scotia, Canada: protocol for a mixed methods study of care by design.

BackgroundPrior to the implementation of a new model of care in long-term care facilities in the Capital District Health Authority, Halifax, Nova Scotia, residents entering long-term care were responsible for finding their own family physician. As a result, care was provided by many family physicians responsible for a few residents leading to care coordination and continuity challenges. In 2009, Capital District Health Authority (CDHA) implemented a new model of long-term care called “Care by Design” which includes: a dedicated family physician per floor, 24/7 on-call physician coverage, implementation of a standardized geriatric assessment tool, and an interdisciplinary team approach to care. In addition, a new Emergency Health Services program was implemented shortly after, in which specially trained paramedics dedicated to long-term care responses are able to address urgent care needs. These changes were implemented to improve primary and emergency care for vulnerable residents. Here we describe a comprehensive mixed methods research study designed to assess the impact of these programs on care delivery and resident outcomes. The results of this research will be important to guide primary care policy for long-term care.ObjectiveWe aim to evaluate the impact of introducing a new model of a dedicated primary care physician and team approach to long-term care facilities in the CDHA using a mixed methods approach. As a mixed methods study, the quantitative and qualitative data findings will inform each other. Quantitatively we will measure a number of indicators of care in CDHA long-term care facilities pre and post-implementation of the new model. In the qualitative phase of the study we will explore the experience under the new model from the perspectives of stakeholders including family doctors, nurses, administration and staff as well as residents and family members. The proposed mixed method study seeks to evaluate and make policy recommendations related to primary care in long-term care facilities with a focus on end-of-life care and dementia.MethodsThis is a mixed methods study with concurrent quantitative and qualitative phases. In the quantitative phase, a retrospective time series study is being conducted. Planned analyses will measure indicators of clinical, system, and health outcomes across three time periods and assess the effect of Care by Design as a whole and its component parts. The qualitative methods explore the experiences of stakeholders (ie, physicians, nurses, paramedics, care assistants, administrators, residents, and family members) through focus groups and in depth individual interviews.ResultsData collection will be completed in fall 2013.ConclusionsThis study will generate a considerable amount of outcome data with applications for care providers, health care systems, and applications for program evaluation and quality improvement. Using the mixed methods design, this study will provide important results for stakeholders, as well as other health systems considering similar programs. In addition, this study will advance methods used to research new multifaceted interdisciplinary health delivery models using multiple and varied data sources and contribute to the discussion on evidence based health policy and program development.

Knowledge Transfer From Urban to Rural Communities in Nova Scotia: the Community Cardiovascular Hearts in Motion Experience

Knowledge transfer (KT) involves the transfer of expertise, knowledge, skills and capabilities from one knowledge-base to those in need of that knowledge. (1) The present study was based on knowledge transfer from a cardio-chronic disease based intervention from one health district to another within Nova Scotia (NS). In the Capital District Health Authority (CDHA) a research program entitled Community Cardiovascular Hearts in Motion (CCHIM) has successfully lead to risk reduction in patients with high risk for primary and secondary cardiovascular disease. The Guysborough Antigonish Strait Health Authority (GASHA) district collaborated with CDHA to bring the urban community CCHIM program to rural NS.

Visual Diagnosis: Abnormal Nails in an Infant

1. Natalie P. Cunningham* 2. Peter J. Green, FRCP† 1. *Dalhousie University, Halifax, NS, Canada. 2. †Department of Medicine (Dermatology), Capital District Health Authority and Dalhousie University, Halifax, NS, Canada. * Abbreviations: ACE: : angiotensin-converting enzyme NPS: : nail patella syndrome A dermatologist has been following a 3-year-old girl for unusually shaped fingernails noted at birth. Her history is as follows. At age 6 months, the patient’s primary care physician referred her to the dermatology service after the child’s adoptive mother expressed concern about her daughter’s small, misshapen fingernails. The infant was born after a pregnancy complicated by maternal smoking. She was induced at term due to failure to progress and eventually required vacuum extraction, weighing 2.405 kg at birth with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. There had been no concerns with her growth or development, and she was an active and happy child. She took no medications and had no known allergies. Her family history included a biological mother with attention-deficit/hyperactivity disorder and substance abuse and a healthy maternal half-brother. Little was known about the biological father, but the biological mother indicated that the father had abnormal nails. Physical examination at 6 months revealed an alert, well-appearing infant in no acute distress. Vital signs were within normal limits for her age, and she was growing between the 50th and 75th percentiles for height, weight, and head circumference. She was normal in appearance. There were no dysmorphic features on her head, face, or torso. Her fingers were slightly tapered with normal creases. The nails of her fingers on both hands were small and unusually shaped with longitudinal grooving, most pronounced on her thumbnails and less so on the nails of the fifth digits. Her toenails were unaffected. Given the nonspecific nail features, the dermatologist recommended seeing the infant 1 year later. At age …

Pain in Child Health

Correspondence: Dr Patrick McGrath, Pediatrics and Psychiatry, Dalhousie University; IWK Health Centre and Capital District Health Authority, Halifax, Nova Scotia. 5850 University Avenue, Halifax, Nova Scotia B3K 6R8. Telephone 902-470-6511, fax 902-470-6767, e-mail patrick.mcgrath@iwk.nshealth.ca The challenges of complex and recurrent pain in children and youth are beginning to yield to systematic investigation. The current issue of Pain Research and Management contains a special series on pediatric pain based on keynote addresses presented by world-renowned clinicians and scientists at the International Forum on Pediatric Pain held at White Point Beach, Nova Scotia, in October 2011. The articles reflect the increasing sophistication of research and practice in the area and the application of rigorous science in the service of more effective pain control. Goldschneider (pages 386-390) summarizes the knowledge regarding complex regional pain in children and youth, and integrates what is known from adult and pediatric studies to arrive at a new perspective on this debilitating disorder. Stinson et al (pages 391-396) review pain in juvenile idiopathic arthritis, including the novel use of Internet interventions. Asmundson et al (pages 397-405) develop and apply a pediatric version of the very productive fear-avoidance model of pain. This extension of the model opens up new ways of approaching treatment. Logan et al (pages 407411) focus on the context of chronic pain and elucidate the implications of an ecological perspective for understanding the development of chronic pain and broad strategies for intervention. Finally, Levy and van Tilburg (pages 413-417) review the history and new developments in chronic recurrent abdominal pain. In the next decade, a more theoretically sophisticated understanding of chronic and recurrent pediatric pain will emerge. Models that integrate biological, psychological and social aspects will be used in multicentre studies of typical patients, with longer follow-up. These articles provide the basis for major advances in this important field. editorial

Choosing the Right Patient: Planning for Laparotomy or Laparoscopy in the Patient With Endometrial Cancer

Endometrial cancer remains the most commonly diagnosed gynaecologic cancer in North America. The staging and initial treatment of endometrial cancer involves surgery. Laparoscopic surgery is increasingly used as an alternative to laparotomy. Patient selection for laparoscopy can be optimized by examining factors involved in both the choice of surgical approach and the ultimate procedure performed. We wished to identify factors that might be barriers to laparoscopic surgery in women with endometrial cancer who had surgery performed by the gynaecologic oncology group at the Capital District Health Authority (CDHA) in Halifax, Nova Scotia. We conducted a retrospective review of the records of women with endometrial cancer, histologically confirmed preoperatively between 2005 and 2007, who underwent surgery at the CDHA. Between 2005 and 2007 in Nova Scotia, 428 cases of endometrial cancer were diagnosed, and 289 women with a preoperative diagnosis of endometrial cancer underwent surgery at the CDHA. Of these, 66.1% (191/289) underwent a planned laparotomy, and 33.9% (98/289) had a planned laparoscopy. The proportion of attempted laparoscopies increased from 21.9% to 57.1% (P = 0.002) over time, while there was no change in the conversion rate (P = 0.23). Patients with abnormal findings on pelvic examination were more likely to have a laparotomy (RR = 1.5; 95% CI 1.34 to 1.68). Independent predictors of laparoscopic conversion to laparotomy were age 75 years or over (P = 0.03) and non-endometrioid histology (P = 0.002). Our data identify age and non-endometrioid histology as independent factors for conversion of surgery for endometrial cancer from laparoscopy to laparotomy. With this information we can optimize patient selection for laparoscopic surgery. Patients undergoing a conversion to laparotomy do not have a significant increase in surgery time or perioperative morbidity.

The development of community health indicators: a district-wide approach

In response to high rates of chronic disease, the Capital District Health Authority in Nova Scotia recognized a need to move from a focus on acute care in decision making to one that also values a population health approach guided by community health indicators. Stakeholders were surveyed on the choice, knowledge and utility of selected indicators. Respondents reported high scores for changes in their knowledge and attitude regarding community health indicators, and identified priority indicators for action.Decision makers' use of community health indicators was increased by stakeholder involvement, supporting evidence in plain language, and wide dissemination.

Institution-Wide Quantification of Iatrogenic Blood Loss Using a Novel Informatics-Driven Methodology

AbstractAbstract 1530▪ Rationale:Anemia has been shown to have an adverse impact on patient outcomes. In the transfusion literature, various blood conservation and patient blood management systems have been proposed as a way to reduce the burden of anemia. An important component of limiting blood loss is the reduction of iatrogenic blood loss through diagnostic phlebotomy. Studies in the phlebotomy and transfusion literature largely focus on small patient populations on critical care units. Such research provides a great depth of information about those settings, but the impact of diagnostic phlebotomy on the broader inpatient population is unknown. We present a novel method, not previously described in the literature, characterising the extent of iatrogenic blood loss in inpatients at our institution. Methods and results:Following a pilot project, data from September 1 to December 1, 2009 were queried from the institution's laboratory information system. This comprehensive dataset included records of tests conducted during 7503 admissions of patients (n=6733) at twelve individual facilities within Capital District Health Authority (CDHA). There were 70,790 unique laboratory orders, for which a total of 397,770 individual tests were performed. This required a total of 120,398 tubes of blood drawn for a cumulative volume of 648,350 mL from the entire population. The majority of tests were done on a “routine” basis (44,820/ 70,790 orders, 63%); most testing was also done after the first day of admission (59,051/ 70,790 orders, 83%). Patient demographics and testing burden are contrasted by gender in Table 1; males appear to experience a higher testing burden than females, despite similar mean length of stay. There were 618 (9%) of 6733 inpatients having ≥250mL (approximately 1 unit of packed red cells) phlebotomised (Table 1). Phlebotomy volumes are unevenly distributed across the age range, with patients in the two youngest age groups demonstrating lower mean cumulative volumes than older patients (Table 2). When individual admissions are examined, phlebotomy volume per patient is greater in hospitals providing tertiary care, as contrasted to other facilities. At the nursing unit level, the cumulative phlebotomy volume exceeded the population average on patients admitted to critical care units, long term care units and medical wards. This trend was also reflected in the testing performance of service providers, where patients cared for by critical care physicians and internal medicine teams had greater than average phlebotomy volumes. Conclusions:The study demonstrates consistent findings with the critical care literature and identifies a patient population – elderly males – who may be at risk for greater phlebotomy volumes. This study also demonstrates that informatics-based methods can be used to quantify phlebotomy-related blood loss across a broad range of facilities, and identify patient and institution-related variables associated with higher total blood loss. This data set will also provide the ability to model the impact of interventions such as small-volume tubes, direct clinician education initiatives, and could be the basis for a feedback tool in the future. Given the widespread use of laboratory information systems throughout the industrialized world, this approach is readily transferable to other institutions, where it may be used to help reduce iatrogenic blood loss, reduce testing costs and improve patient outcomes.Table 1:Response to study therapy (intent-to-treat set, according to investigator, n=300)Patients n(%)Age in years (mean, median)Length of stay in days (mean, median)Total tests per patient (mean, median)Total phlebotomy volume per patient (mL) (mean, median)Total phlebotomy volume >= 250 ml n (%of gender)Male3638 (54%)62.0, 63.614.4, 5.962.9, 27100.6, 44.0354 (9.7%)Female3095 (46%)63.3, 65.114.5, 6.254.6, 2591.3, 45.0264 (8.5%)Total6733 (100%)62.6, 64.214.5, 6.059.1, 2696.3, 44.0618Table 2:Cumulative phlebotomy volumes by age groupAge_groupTotal volume per patient in mL (mean, median)39 years or less80.3, 32.040 - 49 years80.9, 37.050 - 59 years107.5, 43.060 - 69 years102.0, 46.070 - 79 years99.5, 51.080 or more years95.6, 52.0Total96.3, 44.0 Disclosures:No relevant conflicts of interest to declare.

Parallel Surveys of Specialists and Family Physicians in Nova Scotia Regarding Satisfaction With the Referral Process

Background: The referral letter is fundamental to effective communication between family physicians (FPs) andspecialists. However, this document is frequently cited as a source of frustration for both referring and consultantphysicians. Methods: Aspects of the referral process were identified and assembled in 2 surveys: one distributed to FPs and oneto specialists. The survey used a 5-point Likert scale for each aspect of the referral process. Surveys were mailed to500 family physicians and 500 specialists. Results: There was a 42.4% and 43.8% response rate from FPs and specialists, respectively. Few of the survey itemsstood out as being particularly polarizing. There was no significant difference between FPs and specialists in thelevel of satisfaction, nor among the groups of specialists. Among FPs, those practicing outside of the Capital DistrictHealth Authority (CDHA) had significantly higher overall satisfaction than those practicing within the CDHA. Conclusion: The results of the survey indicate that the referral letter could be improved by focusing on specificaspects of the letter. These points can be targeted at all levels of medical education (undergraduate, postgraduate,and continuing medical education) to help improve a process that is fundamental to our healthcare system. Thedisparity in overall satisfaction between FPs in CDHA and FPs in the rest of the province is intriguing given that CDHAhas the greatest number of specialists.

Chair Massage for Treating Anxiety in Patients Withdrawing from Psychoactive Drugs

Therapeutic massage has been proven to be an effective, nonpharmacologic, alternative for managing state and trait anxiety in a variety of clinical situations. However, no controlled study has investigated this effect in an addiction treatment setting. The aim of this study was to investigate the effectiveness of chair massage for reducing anxiety in persons participating in an inpatient withdrawal management program for psychoactive drugs. The design was a randomized, controlled clinical trial conducted from June 2008 to January 2009. Eighty-two (82) adult patients received inpatient treatment for psychoactive drug withdrawal (alcohol, cocaine, and opiates). This study was conducted at the Withdrawal Management Services at the Capital District Health Authority, Halifax, Nova Scotia. Subjects were randomly assigned to receive chair massage (n = 40) or a relaxation control condition (n = 42). Treatments were offered for 3 consecutive days. Standard counseling and pharmacologic management were also offered concurrently to patients in all conditions. The primary outcome measure was anxiety assessed using the Spielberger State-Trait Anxiety Inventory (STAI). State and trait anxiety scores were determined immediately prior to and following each treatment intervention. Analysis of STAI scores showed a significant reduction in state and trait anxiety for both interventions (p < 0.001). The magnitude in the reduction in state (p = 0.001) and trait (p = 0.045) anxiety was significantly greater in the chair massage group where the effect on state anxiety was sustained, at least in part, for 24 hours. Within the clinical context of this study, chair massage was more effective that relaxation control in reducing anxiety. Further investigation of chair massage as a potential nonpharmacologic adjunct in the management of withdrawal related anxiety is warranted.

Use of an electronic information system to identify adverse events resulting in an emergency department visit

ObjectiveThere is limited information about the nature of adverse events (AEs) that necessitate an emergency department (ED) visit. The objective of the current study was to demonstrate the feasibility of...

Comprehensive survey of red blood cell unit life cycle at a large teaching institution in eastern Canada

Recent blood shortages and the potential clinical impact of red blood cell (RBC) age highlight the need to understand blood supply delivery. This study addresses the characteristics and mechanics of RBC unit trafficking and storage across the transfusion service, previously undescribed in the literature. This retrospective qualitative institutionwide survey assessed the comprehensive RBC life cycle within Capital District Health Authority in Nova Scotia, Canada, during 2007. A total of 15,930 unique RBC units were received from the supplier with 98.6% having mean age of 12.5 days. The mean ages on receipt, transfusion, and time spent in the transfusion system before transfusion were 12, 19.6, and 7.5 days, respectively. Of 12,298 units, 9689 (78.8%) remained within the blood transfusion services (BTSs), while 2609 (21.2%) migrated having been returned a mean of 1.26 times from locations outside BTS (SD, 0.56 times), the latter spending a mean of 18.4 hours outside the BTS. Stationary units had mean age at dispense and time spent in the transfusion system of 19.2 and 6.9 days, respectively, compared to migratory units at 21.3 and 9.9 days, respectively (p < 0.005). A total of 5.2% (636/12258) of units were discarded; 423 of 636 (66.5%) were due to "unit expiry." Quantification of our institutional RBC life cycle highlighted key areas for intervention, such as the reduction of unit migration, especially D- units, as this increased RBC age at transfusion. In the era of limited resources, this method could identify areas where effort should be directed to address unnecessary wastage and aging of RBC units.

Community Pharmacist Services for People With Mental Illnesses: Preferences, Satisfaction, and Stigma

Community Pharmacist Services for People With Mental Illnesses: Preferences, Satisfaction, and Stigma

Self-Monitoring of Blood Glucose in Type 2 Diabetes.

The effectiveness of self blood glucose monitoring (SBGM) in Type 2 diabetes patients is debated. Self monitoring is costly, approximately 6 million dollars each year is spent by the Nova Scotia Pharmacare Program alone. At the Capital District Health Authority in Halifax, Nova Scotia, a study was developed to measure patient self monitoring knowledge and actions. A 42 item pilot survey was developed by a multidisciplinary team and sent to 400 patients with Type 2 diabetes who were followed by a Primary Care Diabetes Case Management team. Initial survey results (N = 116) revealed that 49% of participants test their blood glucose (BG) levels 7 days a week and 37 % of participants test 2 times per day. When asked why they test, 94% indicated that they test to know if their diabetes is under control. 69% indicated they test because their care provider requested them to. When asked about the number of times they were told to test BG 21% stated 4 times every day and 28% stated 2 times every day. Other frequencies were less common. Of those surveyed, 59.9% identified were aware of their last A1c result while 36% were not Sixty-nine percent knew the appropriate postprandial glycaemic targets. However, 36% did not know their postprandial BG target. Forty percent had high BG readings 3-4 times weekly and 23% had high readings every day. Results from our patients followed by diabetes case managers will be compared to those in other jurisdictions and using other models of care. ABSTRACT #161

Practice spotlight: Collaborative care of the elderly

The Centre for Health Care of the Elderly is a multiservice interdisciplinary program within the Capital District Health Authority of Nova Scotia. The program encompasses outpatient and inpatient care, and its cornerstone is comprehensive interdisciplinary assessment, treatment, and education of frail older persons and their caregivers. Outpatient services include the Memory Disability Clinic, which specializes in assessing and managing cognitive impairment, and the Community Outreach Program, which provides comprehensive geriatric assessment in the patient’s home or a long-term care facility. The outpatient team consists of a pharmacist (Susan Bowles), geriatricians, nurse practitioners, registered nurses, and social workers. The Memory Disability Clinic was established in the early 1980s, the team originally consisting of geriatricians and registered nurses. The Community Outreach Program was established about 10 years later, in recognition of the fact that for some individuals, performing assessments in their own home provides better insight into their problems. Approximately 2000 patients are seen annually in the Memory Disability Clinic and 300 patients through the Community Outreach Program. Susan Bowles joined the team for these programs in 2002, when Brian Tuttle, then Director of Pharmacy, and Dr Colin Powell, former Division Head of Geriatric Medicine, made an effective argument for reallocation of funds from another clinical area. The essence of this argument was the aging of the Nova Scotia population, the impact of drug-related problems on hospital admissions of older persons, and the body of evidence supporting the role of pharmacists in the care of elderly people. Patients are referred to geriatric outpatient services by their primary care provider, with referrals triaged according to complexity and urgency. A comprehensive geriatric assessment consists of a thorough history (cognitive, functional, medical, medication, and social), review of laboratory results, detailed cognitive and physical examinations, and an assessment of mobility. During an assessment, one team member obtains collateral information from family or caregivers, while the other team member sees the patient. If the pharmacist sees the patient, she is responsible for all aspects of the history and physical, cognitive, and mobility assessments. The physical examination, with particular emphasis on the neurologic and musculoskeletal systems, is targeted to identify findings suggestive of disease or drug effects that may be presenting atypically as cognitive or functional decline. The cognitive assessment consists of a battery of standardized tests to determine if a memory problem is present and, if such a problem is identified, its most likely cause. The medication history is an essential component of the geriatric assessment, as drugs are often overlooked as a contributing factor to cognitive and functional decline in this population. Once the assessment is complete, the case is reviewed with the attending geriatrician. This process involves discussion of the overall impression, the need for referral to other disciplines (e.g., physiotherapy or social work) or geriatric services (e.g., home care, seniors mental health, or geriatric day hospital), the need for further testing (e.g., a neuropsychologic assessment), and a treatment and monitoring plan (which often includes discontinuing medications). The pharmacist and geriatrician then meet with the patient and family to review the diagnosis (during the first assessment) or progress (during follow-up assessments), the need for other services or testing, and the treatment plan. After the visit, the pharmacist dictates a detailed consultation letter to the primary care provider, which is reviewed and signed off by the geriatrician. At present, Dr Bowles devotes 2 days per week to outpatient programs, with 1 day every 2 weeks set aside for the