Think Ottawa Medicine

Clinical Care

The provision of high quality compassionate care remains at the centre of the mission of the Department of Medicine and our commitment to academic medicine enables us to effect evidence-based medicine to support our patient-care decisions.

Departmental members are based at all 3 campuses of the Ottawa Hospital as well as the Rehabilitation Centre, The University of Ottawa Heart Institute and Bruyère Continuing Care.

The majority of inpatient care at these hospitals is provided by our members, either as the admitting divisional physician or through consultative services. Consequently, we have been at the forefront of exceptional clinical undertakings such as a dedicated Thrombosis service, acute STEMI program and pandemic planning. We have championed efficiencies in discharge planning, ER consult-decision time and a mature Physician Assistant Program that will allow our medical trainees to concentrate their efforts on education.

The Department of Medicine supports a wide range of clinical initiatives such as a multi-disciplinary Pulmonary Hypertension program, bone marrow and solid organ transplants, diagnostic and therapeutic endoscopies, diabetes out-reach program to the Champlain LHIN, stroke prevention, treatment and rehabilitation, in-hospital early palliative care, and advanced clinical care of patient with hepatitis C.

Excellence and Innovations in Clinical Care for 2010, by Division:

Cardiology

• Cardiology has instituted a unique (for Canada) dedicated Cardiology-Oncology Referral Clinic at the General Campus that is designed to provide timely patient access to cardiologists in order to optimize the delivery and safety of potentially cardiotoxic cancer therapy.
• Dr. Michel Le May recently led a project that used hypothermic cooling for STEMI arrest patients with about a 50% discharge rate. Findings were presented at Canadian Cardiovascular Society and American Heart Institute this year.

Critical Care

• Critical Care members are involved as principal members initiatives such as a REACHOUT project to improve education and care in community hospitals, and a Royal College-sponsored project involving simulation education and evaluation of performance in Iqalait.
• Dr. Hilary Meggison has received CIHR funding for her ICU long-term follow up clinic.  The scope of this clinic is to ensure complete and comprehensive follow up of the unique set of medical issues that have been identified in patients who survive critical illness.  The clinic is also part of an initiative to evaluate functional and quality of life outcomes in ICU survivors and their primary caregivers.  Information gathered from patients and caregivers will help to identify areas of study and areas to improve upon for the future.

Dermatology

• The Division successfully launched the Mohs surgery unit that will see higher cure rates for skin cancer, 75% cost savings and more cosmetic results vs radiotherapy.

Endocrinology & Metabolism

• The Tools For Transition Program, led by Dr. TC Ooi, was established to improve the transition of patients with type 2 diabetes from our specialty site back to their family physician.  After conducting focus groups and surveys with family physicians and specialists, and doing a detailed chart audit of patients who are discharged or default (do not return for planned follow-up) from our diabetes clinics, the Endocrinology and Metabolism program has implemented several new tools to facilitate a smooth and successful  transition. These include defined discharge criteria, a structured discharge letter template with patient-specific treatment targets and recommendations, a rapid re-referral system for patients who need to be seen again, a patient discharge letter summarizing the recommendations for ongoing care and a patient reminder mailed 3 months after discharge highlighting the importance of a follow-up appointment with their family physician. The introduction of these tools will increase the confidence of patients and providers in the transition of care of type 2 diabetes patients back to the family physician.
• As part of the The Ottawa Hospital committment to improving the quality of inpatient diabetes care, preprinted insulin orders were developed and implemented by a multidisciplinary team within the Endocrinology and Metabolism program.  After being successfully piloted in nephrology and cardiology, the preprinted orders  were rolled out across The Ottawa Hospital, and Heart Institute on Sept 28th 2010. They will be launched at the Rehabilitation Centre shortly. Seven weeks later, over 50% of insulin orders are being written on these new forms and the feedback has been very positive. The staff physicians, Endocrinology and Metabolism Fellows and diabetes nurse specialists were all involved in numerous education sessions for physicians, trainees and nursing staff and provided a laminated diabetes reference card to support the launch of the preprinted orders. Sharon Brez, the APN in Endocrinology and Metabolism, Silvana Sicoli, the program’s quality analyst, and Dr. Janine Malcolm have been instrumental in launching this major initiative.
• Members of rheumatology, cardiology, nephrology, neurology, dermatology, and endocrinology/metabolism are participating in a proof of concept study on e-consultation. Primary care providers submit a consultation which includes relevant patient information and a clinical question using a secure web-based portal to the specialist. After an email notification, the specialist replies to the consultation within 7 days.  To date, 34 family physicians are participating and 50 e-consultations have been received. This project is supported by the AFP Innovation Fund, the Champlain LHIN and the Ministry of Health.
• A thyroid biopsy clinic was recently established at the Foustanellas Endocrinology and Diabetes Centre. Bedside thyroid biopsies are now being done by Drs. Arnaout and Lochnan. This new service reduces wait times for thyroid biopsies and provides valuable training for our Endocrinology and Metabolism fellows.

General Internal Medicine

• Successful creation of the Institute for Clinical Evaluative Sciences (ICES) satellite site. This initiative will expand the capacity of ICES to conduct research that contributes to the effectiveness, quality, equity and efficiency of health care and health services in Ontario through an increased number of scientists and an increased breadth of scientific expertise.

Geriatrics

• Launched the GEM (Geriatric emergency management) regional program at The Ottawa Hospital, Montfort/QCH/valley hospitals and Cornwall that will identify high risk seniors who come to the ER. In an attempt to prevent a revisit the GEM nurse initiates early referral to specialized geriatric services and community supports for further assessment, intervention and in-home services.
• Intiated the Regional Geriatric and Community Intervention Program (RGCIP), aimed at optimizing the safety and independence of local seniors. It is a regional program funded by the MOHLTC. We now have successfully implemented an evidence-based model for Geriatric Emergency Management (GEM) in nine Emergency Departments across the region. The RGCIP GEM model includes a 2-stage screening process for targeted patient identification followed by a focused geriatric assessment performed by a GEM Nurse. As geriatric syndromes are identified, the GEM Nurse initiates early referral to specialized geriatric services and community supports for further assessment, intervention and in-home services, as indicated. The Nurse may also review the case with the Geriatrician if this is required. The GEM model is utilized to enhance the usual care of seniors in the ED, thus creating a new frontier aimed at improving the safety and quality of ED care for high-risk seniors.

Division of Hematology

• The oral anticoagulation management program achieves an 80% time in range which exceeds any published results from clinical trials or similar services. The LHIN has funded a pilot program to deliver Thrombosis Program services to Montfort, Pembroke, Hawkesbury and Cornwall- the latter 3 had over 200 unattached patients coming to their ERs, some weekly, for warfarin management.

Infectious Diseases

• The division acquired MOH funding for a multidisciplinary viral hepatitis clinic. We are the first hospital-based clinic of its type in Canada and our pilot is the model for clinics in Ontario.

Medical Oncology

• Involved in the opening in the Queensway Carleton Hospital Cancer Centre

Nephrology

• Under the direction of Marcel Ruzicka, the Renal Hypertension Program is gaining recognition for its excellence in clinical care; as a platform for clinical & translational research and as an innovative teaching program for Family Medicine Residents, having won an award at AIME.
• “New Start” Hemodialysis Unit at the Civic Campus is being led by Dr. Marcel Ruzick. It is a separate unit designed for new dialysis patients (first 6-8 weeks) where the focus is on education and is provided by nurses, dietitians, SWs & physicians. Home Dialysis and Transplantation are promoted; dialysis access issues are sorted out; end of life decision making/advance directives are addressed. This has lead to an increase in patients transferring to home dialysis.  Other outcomes are being assessed.
• Under the direction of Ann Bugeja, the In-centre nocturnal Hemodialysis program at the General Campus provide long overnight dialysis for those who need improved phosphorus clearance or do not tolerate fluid removal over usual 4 hour treatments.
• Lead by Ayub Akbari, the Telehealth Nephrology follow-up Clinics in Cornwall & Hawkesbury now has 11 Nephrologists participating. We are embarking on tele-education options that would provide dialysis treatment education for patients in Cornwall.
• Dr. Greg Knoll is directing the “domino” living donor renal transplant procedure (3 transplants simultaneously). Dr. Knoll also organized the first in Canada “donor after cardiac death” transplant several years ago.

Neurology

• Dr Mike Sharma was awarded a 1st Prize 2010 Ottawa Hospital Quality for the initiative “Reducing Door-to-needle times for the administration of t-PA to acute stroke patients”. In actual numbers, the DTN time was reduced from 74 to 53 minutes, well below the guideline target of 60 min.  You loose about 2 million neurons by the minute in acute occlusions.
• Initiatives in the urgent TIA/ stroke clinic provided better stratification of intervention based on risk has reduced eventual stroke after TIA by 2/3.

Palliative Care

• In October 2010, the 36-bed Palliative Care unit at the Elisabeth Bruyère Hospital was restructured and divided into 2 separate units; an acute unit (20 beds) and a sub-acute unit (16 beds). The 20-bed acute palliative care unit (5th floor of the Elisabeth Bruyere Hospital) admits patients with complex needs that require high-intensity care by a specialist interprofessional palliative care team. Some patients require short stays of only a few days to get their symptoms controlled, at which time they are discharged back to the community or to a residential hospice. Some patients may have life expectancies of days to weeks, while others may still have many months of life remaining but need symptoms controlled in order to improve their quality of life. The unit also occasionally admits patients whose diseases are well controlled with treatments such as chemotherapy or radiotherapy but need hospitalization to control severe symptoms such as pain, nausea or shortness of breath. The unit admits patients with cancer and non-cancer diagnoses such as end-stage heart, lung and neurological diseases. The Division’s physicians take on the role of the most responsible physicians (MRP) for the patients on the unit. Physicians see patients every day of the week (Monday to Sunday) and are available 7 days a week, 24 hours a day.  The unit is a regional resource and admits patients requiring this level of care from across the Champlain region. The interprofessional team consists of nurses (RNs and LPNs), physicians, personal support workers, a social worker (part-time), a pharmacist, a psychologist (part-time), an occupational therapist (part-time), a physiotherapist (part-time), a chaplain (part-time), a recreational therapist (part-time), clerk (part-time) and volunteers.
• The 16-bed Bruyère Sub-acute palliative care unit (5th floor of the Elisabeth Bruyere Hospital) admits patients requiring end-of-life care (last days and weeks of life) whose needs are less complex than those on the acute palliative care unit.  While the Division’s physicians are the MRPs, by mid 2011, the MRP role will be taken on by family physicians, mainly from the Academic Family Health Team at Bruyere Continuing Care (Bruyere and Primrose Sites), with the Division’s physicians providing specialist consult support through the PPSMCS. An interprofessional team (shared with the acute palliative care unit) cares for patients on the unit. Physicians see patients two to three times a week (or every day if required) and are available 24-hours per day, seven days a week.

Physical Medicine & Rehabilitation

• Recent creation of an Acquired Brain Injury Rehabilitation Day Hospital Program. The objective of the program is to assist patients with functional improvement  where the focus is on addressing diffuse cognitive dysfunction as well as physical impairment post ABI . The program is goal oriented, interdisciplinary and provides therapeutic interventions that address cognitive, behavioural, psychosocial and physical needs.

Respirology

• A pleurex program led by Dr. Kayvan Amjadi allows for the treatment of malignant pleural effusions and malignant ascites with indwelling pleurex drainage catheters. The patients are able to go home and have their effusions drained by homecare nurses. This program has saved thousands of inpatient days in hospital and has allowed patients with terminal cancer to spend their final months at home instead of mostly in hospital.

Rheumatology

• An advanced Therapeutics Program is being developed for >1000 patients on biologic agents for inflammatory arthritis and systemic autoimmune rheumatic diseases.