Division of Cardiology. Department of Medicine Compendium of Divisional Activity division of CARDIOLOGY

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1 Division of Cardiology Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY

2 Physician Resources The Division consists of academic cardiologists ( full-time and part-time) located primarily at the Halifax Infirmary Site. The total FTE appointment for the Division of Cardiology is 9.. At the Dartmouth General Site there are fee-for-service community-based cardiologists who are members of the Division of Cardiology but not members of the AFP (Dr. Paul Mears, Dr. Jason Yung and Dr. Alex MacLean.) Dr. Alex MacLean is a recent appointment to the Dartmouth General Site effective November and is a welcomed addition to the community cardiologists and General Internal Medicine Group at the Dartmouth General Hospital. Division Highlights The Division of Cardiology, Department of Medicine, Dalhousie University functions within the Heart Health Program of Capital Health in partnership with the Divisions of Cardiovascular Surgery and Vascular Surgery, Department of Surgery, Dalhousie University. Drs. H.K. Beydoun, Simon Jackson and Ata Quraishi were promoted to Professors of Medicine in July. Dr. Syed Najaf Nadeem and Dr. Miroslaw Rajda were promoted to Associate Professor in July. Dr. B.A. Clarke received his fellowship from the American College of Cardiology in June. to address this issue; nevertheless, the wait list remains above standard. This is an area of great concern for the division. In the year,,9 echocardiograms were performed (an increase of % over the previous year.) Wait times reached a high of weeks with national standards set at weeks. Due to the unrelenting efforts of the administration and echocardiography laboratory the wait time now has decreased to weeks. This is expected to decrease further with approval of the purchase of another echocardiography machine. Holter monitors, loop recorders and stress with nuclear examination wait times remain above standard. The Division is very grateful to Dr. Dongsheng Gao who joined the Division as a locum physician for the year - to assist the Heart Rhythm Group. Dr. Gao completed his locum in June and has moved on to join the group of community cardiologists at Cape Breton Regional Hospital. In the Division of Cardiology underwent its regularly scheduled end of first term Divisional Survey. The survey was chaired by Dr. David Petrie, Emergency Room physician, Capital Health, Dalhousie University. The division wishes to publically thank Dr. Petrie and his committee for their exhaustive review and helpful report which was presented to the Department of Medicine Executive in the spring of. showed expansion of our new transcatheter aortic valve implantation (TAVI) program with a total of procedures completed in - for a total of successful TAVI procedures for the program. It is anticipated the program will continue to expand in following years. All invasive diagnostic investigations and interventions provided by the Cardiac Catheterization Laboratory remain within standard wait times. Cardiac surgery wait times similarly remain within standard. The Heart Rhythm Laboratory completed procedures over the last year and wait times for diagnostic and interventional heart rhythm procedures are now within standard. In Ambulatory Care there were,9 clinic registrations with noted expansion of the Atrial Fibrillation Clinic and Connective Tissue Clinic. also saw the development of our newly launched Cardio-Oncology Clinic run by the Heart Transplant/Heart Function Group in collaboration with Oncology. The Division of Cardiology recognizes that we are the sole providers of diagnostic, interventional and surgical care in the Province of Nova Scotia together with the Divisions of Cardiovascular Surgery and Vascular Surgery within the Heart Health Program of Capital Health. We pride ourselves in providing timely, responsive, appropriate and efficient service to the entire cardiovascular community of the Province of Nova Scotia. Referrals for echocardiograms and specialty echocardiograms continue to rise with rising wait lists which remain above standard. The Division of Cardiology and Capital Health have invested a great deal of effort into reorganization of schedules, recruitment of sonographers and expansion of our echocardiography capital equipment Department of Medicine Compendium of Divisional Activity - division of cardiology

3 New Programs, Partnerships & Innovations Atrial Fibrillation Clinic The Atrial Fibrillation (AF) Clinic was established in November, using industry and research funding. It has functioned primarily as a method to educate, assess and provide management recommendations for patients who present to the Emergency Department with new onset AF. To date, over patients have been seen in the AF Clinic. This is a multidisciplinary clinic consisting of a nurse, pharmacist and cardiac electrophysiologists. The nurse is the primary caregiver in the clinic, gathering clinical information on the patients, communicating with the patient and family physician after referral to provide education and guidance on treatment options and providing education in person on the day of clinic. The diagnostic investigations and management plan is reviewed with the cardiac electrophysiologist and discussed with the patient as a group. The pharmacist (Michael Callaghan) has been a late addition to the clinic, as a pilot project. So far, the addition of the pharmacist has been helpful both to the patients, nurse and physicians. No data on the value of the addition of the pharmacist has been collected. The research study surrounding the AF Clinic has been a before-after study; this data was presented at the DOM Research Day. The standard (before) group (n=7) was comprised of patients presenting to the Emergency Department (Halifax Infirmary, Cobequid or Dartmouth General) with new-onset AF between January, 9 and October and were seen by a specialist. The AF Clinic (after) group (n=) were comprised of the same patients but seen in the AF Clinic. In summary, no differences in baseline characteristics between the AF Clinic group and the standard arm were observed. No differences in anti-coagulation rates were observed prior to clinic visit in either arm. Post clinic visit, the AF Clinic arm demonstrated a significant improvement in OAC (oral anticoagulation) use in patients with CHADS (score for determining stroke risk for those with AF)>; in the CHADS = group the AF Clinic prescribed OAC in % of patients vs..% of patients in the standard arm (P<.). In the CHADS group, 7% vs. 7.% received OAC (p=.). This same trend held for patients with a CHA DS -VASc=:.9% vs. % (p=.). Both groups demonstrated a reduction in AF-related Emergency Department visits and hospitalizations pre and post clinic visit. The AF Clinic, however, demonstrated a significant reduction in both repeat Emergency Department visits (HR., p=.) and hospitalizations (HR., p=.) after assessment, as compared to the standard group. The number needed to treat (NNT) to prevent Emergency Department visit at year is patients; the NNT to prevent hospitalization at year is patients. A nurse-run, physician supervised AF Clinic is superior to specialist-only care in our institution in appropriate use of oral anti-coagulation and important clinical outcomes including AF-related Emergency Department visits and hospitalizations in this controlled clinical trial. Transitioning care models in this manner will likely result in better, more efficient and cost-beneficial care of patients with AF. We plan to further explore other AF quality indicators in the AF Clinic as compared to standard care, as well as the addition of other health care personnel, such as the value of the pharmacist. Cardio-Oncology Clinic, Halifax Infirmary Site, QEII Health Sciences Centre The Cardio-Oncology Clinic was established at the QEII June within the existing infrastructure of the Heart Failure Clinic in the Division of Cardiology, attended by two cardiologists (Dr. Brian Clarke & Dr. Miroslaw Rajda). It is a cardiac specialty clinic designed for the rapid assessment, investigation, and management of cancer patients at risk, or, established cardiac complications of cancer and cancer treatments. Cardio-toxicity is a common adverse event of many cancer treatments and with the advent of newer systemic and targeted therapies, the field of cardio-oncology has been developed to specifically manage this unique patient population. Currently, this clinic provides a direct link for medical oncologists and hematology-oncologists at the QEII, cardiologists, or specialists involved in cancer care, to access specialty cardiac services related to the cardiac complications of cancer and cancer treatments. Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY

4 Work for Nova Scotia Department of Health & Wellness Dr. Ata Quraishi, Dr. Michael Love and Dr. Jafna Cox have developed guidelines for management of acute coronary syndrome patients with chronic kidney disease undergoing cardiac catheterization and percutaneous coronary intervention. This project is ongoing in collaboration with Cardiovascular Health Nova Scotia (CVHNS). Dr. Michael Love and Dr. Iqbal Bata were primary authors of the update to the anti-platelet section of the Cardiovascular Health Nova Scotia Guidelines for Acute Coronary Syndrome. The Division is currently looking at further expansion initiatives to offer drip and ship for high risk acute myocardial infarctions treated with thrombolysis throughout the Province in order to facilitate earlier access to revascularization therapy. Dr. Michael Love and Dr. Jafna Cox continue to act as Clinical Advisors to Cardiovascular Nova Scotia. Public Education Atrial Fibrillation Clinic Education Sessions In September, the division began offering public education sessions on the subject of atrial fibrillation. The sessions are presented by the atrial fibrillation clinic nurse, with support from the AF clinic pharmacist, to elaborate on drug-related content, and to answer questions on the subject of medications prescribed for AF. The nurse gives a -minute presentation, covering the mechanism of the arrhythmia, causes and contributing conditions, clinical implications and associated risks. The risk of stroke and appropriate measures to mitigate this risk are the main objectives. In addition, treatment options are reviewed. Patients are advised on when to seek emergency care, and when it is safe to stay at home. Monthly sessions have offered a general overview, and special drug information presentations have been given by the atrial fibrillation clinic pharmacist. On average, we have seen attendees per session. These include patients, family members and interested members of the general public. Attendees are asked to evaluate the presentation (anonymously), on separate quality points, and response has been overwhelmingly positive, with an average rating of.9 out of a possible points. Quality & Patient Safety Dr. Robbie Stewart Adverse events felt to be of educational value were again reviewed at the end of each resident rotation through the academic year. The rounds are led by the senior Cardiology resident who has attended in the Coronary Care Unit for the preceding week rotation. Any significant morbidities or mortalities are reviewed with a focus on identifying learning points in the cases which can improve patient care in the future. Quality Assurance Rounds were performed on the routine use of transesophageal echo prior to atrial fibrillation ablation. A cohort of patients was reviewed and risk factors for the presence of left atrial appendage thrombus were found. Overall there was a subgroup of patients identified that might be appropriate for having an ablation without the use of transesophageal echo. Finally, at the request of the District Medical Association Quality Committee, a task group was identified to deal with a long-standing issue regarding increased length of stay in patients with heart failure as had been documented by CIHI data. The working group reviewed pertinent data and identified areas that could be targeted that might improve length of stay. The working group is currently well along its way towards creating a care pathway with the hopes that this will standardize care and help improve length of stay in this challenging patient group. Dr. S. Gabrielle Horne Accreditation Canada designated the Maritime Connective Tissue Clinic Family Screening Program as a leading practice. This designation is awarded to programs that are particularly innovative and effective in improving quality. Department of Medicine Compendium of Divisional Activity - division of cardiology

5 Clinical Services Cardiologists provide emergency coverage, inpatient, ambulatory, diagnostic and catheterization clinical services. Specialized cardiology care is provided for patients in the Capital District Health Authority; tertiary care for the province and quaternary care for electrophysiology, adult congenital heart disease and some interventional procedures including: Cardiac Catheterization Lab / Percutaneous Intervention Program/ Rescue PCI program Electrophysiology Lab/Program Echocardiography Lab Nuclear Stress, Stress Lab ECG, Holter, Loop, Tilt Pacemaker/Device Clinic Heart Function Clinic Emergency Coverage Cardiologists provide hour, 7-day/week emergency and on-call coverage for patients in Capital Health. Subspecialty hour 7-day/week call is provided for interventional procedures, the Coronary Care Unit, ECG interpretation, echocardiography, cardiac transplantation and electrophysiology and general consultation from the Atlantic Region. Inpatient Services Cardiology continues to be responsible for a total of beds at the Halifax Infirmary Site, Capital Health. The Cardiology Group provides hour 7 day a week emergency on-call coverage for all inpatients with direct response to the Emergency Department. In addition to their responsibility for the patients admitted to the cardiology inpatient units, cardiologists also provided weeks as attending physician staff for MTU, and. weeks on call to the Emergency Department. The Division provides tertiary care for the province in the form of a Transfer Service where patients are referred from across NS and PEI; triaged on a priority basis and are transferred to the Halifax Infirmary according to acuity on a daily basis. These admissions are direct admissions from the home hospital and undergo necessary investigations and return to home hospital the following day. In,, transfer patients were admitted on the Cardiology Transfer Service and returned to home hospital in less than hours. Table Cardiac Health in Motion (Cardiac Rehab) Cardiac Transplant Program Adult Congenital Heart Disease Emergency Liaison, Early Discharge Clinic Connective Tissue Clinic Unit/Designation # Beds. CCU* Stemi EP Unit. 7 IMCU.B Transfer Total Inpatient Beds 7 Cardiac Day Unit CDU.B Total Beds *One bed on the CCU is kept open to allow for the next Stemi patient to be admitted. Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY

6 s Bed & Occupancy The inpatient wards of IMCU and Ward. continue to be extremely busy with a 9% occupancy rate and average length of stay of. days on the Intermediate Care Unit and an average length of stay of. days on Unit. General Cardiology. The Coronary Care Unit continues to be the tertiary care referral for the Coronary Care Intensive Care Unit for the Province of Nova Scotia as well as the primary Coronary Care Intensive Care Unit for all cardiac patients admitted through the Halifax Infirmary Emergency Room or triaged directly to the Halifax Infirmary Site, Cardiac Catheterization Laboratory as part of the primary PCI (percutaneous coronary intervention) or Rescue Program. We have an excellent reciprocal relationship with our referring centres and patients are returned to their referral centres on a prompt basis allowing us to provide continuous patient flow and access to tertiary care facilities for the entire province. The average length of stay in CCU is.9 days. Figure HI. Coronary Care Unit Average Bed Day Utilization by Fiscal Year QEII Health Sciences Centre, 9 -,,,,, Bed, NOTE: Two beds on. are dedicated to Stemi and Post EP for critical monitoring Figure HI. IMCU Nursing Unit Average Bed Day Utilization by Fiscal Year QEII Health Sciences Centre, 9-7, ys Bed Day,,, Bed Used,9,,9,, Avail,9,,,,977,,, Figure HI. Nursing Unit Average Bed Day Utilization by Fiscal Year QEII Health Sciences Centre, 9 -, ays Bed Da,,,,,, The. unit is comprised of beds. beds dedicated to Coronary Care, bed dedicated to Stemi, and bed dedicated to EP. One objective of the unit is to ensure there is always one empty bed available ready to receive the next Stemi patient. The. unit also makes an active effort to keep one bed open to receive additional Coronary Care patients. The EP bed allocation is typically empty Thursday, Saturday and Sunday. All these factors cause the occupancy to appear understated in figure which is based only on a snapshot of those beds at midnight. Going forward, the unit plans to close the available Stemi beds within Star and close the EP bed when not in use. This should provide a more realistic picture of the unit s occupancy in future reports. Figure HI. Coronary Care Unit Inpatient Bed Occupancy Rate by Fiscal Year QEII Health Sciences Centre, 9 - % 9% %.7%.% 7% % pancy Percent Occu % % % % 7.9%.% 7.%,, %, On Ser Used,7,,,,9 Avail,7,,,7, Bed Used,,,7,7, Avail,,99,,, % Two beds are dedicated to Stemi and Post EP for critical monitoring. Department of Medicine Compendium of Divisional Activity - division of cardiology

7 Figure HI. IMCU Nursing Unit Occupancy Rate by Fiscal Year QEII Health Sciences Centre, 9 - % ancy Percent Occupa 9% % 7% % % % % 9.9% 9.% 9.7% 9.% 9.% Admissions and transfers in to CCU, IMCU and Unit. are shown. As per discussion with Divisional administration the logic was revised in 9- so that any transfers from EMERGENCY are classified as Admissions. Transfers refer to patients from other QEII units. patients admitted (and patients transferred from other units) to coronary care in for a total of, admissions. Figure 7 Figure 9 HI. Nursing Unit Inpatient Admissions and Transfers In by Fiscal Year QEII Health Sciences Centre, 9 -, and Transfers Admissions,,, % % % HI. Coronary Care Unit Inpatient Admissions and Transfers In by Fiscal Year QEII Health Sciences Centre, 9 -, Transfer In Admits,7,,,, Total,,97,,9,9, Figure HI. Nursing Unit Occupancy Rate by Fiscal Year QEII Health Sciences Centre, 9 - % and Transfers Admissions Figure HI. Coronary Care Unit Inpatient Average Length of Stay () by Fiscal Year QEII Health Sciences Centre, 9 - ancy Percent Occupa % 9% % 7% % % % % 9.% 9.% 9.7% 9.% 9.% Tranfers In 9 97 Admits 9 7 Total ,9, Figure % % % HI. IMCU Nursing Unit Inpatient Admissions and Transfers In by Fiscal Year QEII Health Sciences Centre, 9 -, and Transfers Admissions,, Transfer In 9 77 Admits,9,9,,, Total,,,7,,7 The Average Length of Stay (ALOS) is shown for the past five fiscal years. In, the ALOS in CCU increased to.9 days. The ALOS in IMCU increased to. days. The ALOS on Unit. has decreased with an ALOS for, of. days compared to. days the previous year. Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY 7

8 Figure HI. IMCU Nursing Unit Average Stay () by Fiscal Year QEII Health Sciences Centre, 9 - Figure HI. Nursing Unit Average Stay () by Fiscal Year QEII Health Sciences Centre, Tertiary Care There were, tertiary care transfers for the fiscal year under the direction of Bed Manager, Dr. Ata Quraishi. These patients are admitted on the hour transfer service from other provincial hospitals and PEI for urgent tertiary care. The patients receive the intervention and are returned to their home hospital for recovery on the following day. There was expansion of the Primary PCI and Rescue PCI Program with a total number of primary PCIs and 9 call-backs after-hours to the Cardiac Catheterization Laboratory. Fiscal year trending data are shown: Figure Cardiology Tertiary Transfers by Fiscal Year QEII Health Sciences Centre, 9 -, ts Transferred # Patient,,, Source: Approach Database,9,,7,, NOTE: These patients are admitted on the hour transfer service from other provincial hospitals and PEI for urgent tertiary care. The patient receive the intervention and are returned to their home hospital for recovery on the following day. Wait times for all invasive and non-invasive cardiac services are tracked compared to national wait times and monitored on a month-to-month basis. Figure Cath Wait Times for CCU QEII Health Sciences Centre, -. # CCU Standard # Figure Cath Wait Times for IMCU QEII Health Sciences Centre, IMCU-/ IMCU-S Standard ays # Da. Department of Medicine Compendium of Divisional Activity - division of cardiology

9 s Figure Cath Wait Times for Ward QEII Health Sciences Centre, - # Day Standard Ward.-S Inpatient Consultations An inpatient consultation service is provided by cardiologists. Inpatient consultation remains a shared responsibility with the Division of General Medicine. Cardiology provides a less than hour, and usually same day consultation service, at the sites of the QEII and for the IWK. Exact number of inpatient consults is unavailable but what is known is that,997 major consults were provided across all sites in this would include all Cardiology Inpatient, MTU, Senior Internist and MTU major consults. Ambulatory Care Cardiology Clinics include: Heart Function, Heart Transplant, Adult Congenital Heart Disease, Atrial Fibrillation, Pacemaker/Device, Emergency Liaison, Early Discharge, Connective Tissue, Hearts in Motion (Cardiac Rehab/Heart Health) and Pre-admission clinics (pre cardiac catheterization procedures). With continued increases in all ambulatory activity each fiscal year more clinic space is needed. The following chart shows all ambulatory care registrations for Cardiology, including both physician and non-physician. There were,9 registrations for all cardiology clinics in the year. This is an increase of.% from the previous year. There were an additional,9 chart checks performed in not reported in the following figures. Figure 7 All Cardiology Clinics (General & Specialty) New and Return Ambulatory Care Registrations QEII Health Sciences Centre, 9 -,,, gistrations Reg,,,, CodeMissing,9,,,,7 New,,77 9,,9,9 Return,9, 9,9 9,7 9,9 Total,7,9,,,9 % New.%.%.%.% 7.% Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY 9

10 The following graphs show registration numbers for General Cardiology and Electrophysiology for the past five years. Figure General Cardiology New and Return Physician Ambulatory Care Registrations QEII Health Sciences Centre, 9 -, gistrations Reg,,,,, Figure Cardiology Congenital Heart Clinic New and Return Ambulatory Care Registrations QEII Health Sciences Centre, 9 -, istrations Reg CodeMissing New 9 Return Total % New.%.% 9.%.%.% Figure Cardiology Pre-Admit New and Return Ambulatory Care Registrations QEII Health Sciences Centre, 9 -, gistrations Reg,,,, CodeMissing 7 New,,,,9, Return 9 79 Total,7,,,,9 % New 7.%.7% 7.%.%.% CodeMissing New,9,,,,9 Return,,,,,97 Total,,,9,9,9 % New.9%.%.%.9%.% Figure Figure Figure 9 Cardiac Devices New and Return Ambulatory Care Registrations QEII Health Sciences Centre, 9-7,, Cardiology Heart Function Clinic New and Return Ambulatory Care Registrations QEII Health Sciences Centre, 9 -,, Cardiology Electrophysiology New and Return Ambulatory Care Registrations QEII Health Sciences Centre, 9 -,, gistrations Reg,,,, gistrations Reg,,,,, gistrations Re,,,, CodeMissing 9,9, New 9 9 Return,9,7,7,, Total,9,7,,,9 % New.9%.9%.%.%.7% CodeMissing New 9 Return,,7,,,7 Total,7,9,99,97, % New.%.%.%.%.% CodeMissing 7 New 9 7, Return,9,9,,9,7 Total,7,,9,9, % New 9.%.%.%.% 7.7% Department of Medicine Compendium of Divisional Activity - division of cardiology

11 Figure Cardiology Heart Transplant Clinic New and Return Ambulatory Care Registrations QEII Health Sciences Centre, 9 -, gistrations Reg, CodeMissing 9 New 7 Return 9,9 Total 9 9,7 9 % New.%.%.%.%.% Ambulatory Clinic Wait Times The wait time for urgent referrals is about days, above the recommended standard of 7 days. The wait time for semi-urgent referrals are close to the standard of month. The wait time for non urgent consults is about months with the standard set at weeks. General Cardiology and Electrophysiology (EP) wait times are now being reported separately. This has helped put additional focus on the resource constraints in EP. Figure General Cardiology New Urgent Consults Ambulatory Care Clinic Average Wait Time () by Quarter QEII Health Sciences Centre, - Figure General Cardiology New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time () by Quarter QEII Health Sciences Centre, - Average Wait Time Standard Wait Time Count 7 79 Minimum Wait Maximum Wait 7 % Within Standard % % 9% % 7% % % % Figure 7 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait 9 % Within Standard % % 9% % % 7% 9% 9% General Cardiology New Non-Urgent Consults Ambulatory Care Clinic Average Wait Time () by Quarter QEII Health Sciences Centre, - Average Wait Time Standard Wait Time Count 7 7, Minimum Wait Maximum Wait % Within Standard % 9% % % % % % % Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY

12 Wait times for urgent electrophysiology referrals was. days over the year, which is above the standard of days. Figure Cardiology Electrophysiology New Urgent Consults Ambulatory Care Clinic Average Wait Time () by Quarter QEII Health Sciences Centre, - Wait times for non-urgent Electrophysiology referrals have decreased to. days in compared to the benchmark of 9 days, and has improved remarkably compared to the same period last year when wait times were at 7. days. Figure Cardiology Electrophysiology New Non-Urgent Consults Ambulatory Care Clinic Average Wait Time () by Quarter QEII Health Sciences Centre, - Figure Cardiac Rehabilitation Program New Non-Urgent Consults Ambulatory Care Clinic Average Wait Time () by Quarter QEII Health Sciences Centre, - Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait 7 % Within Standard % 7% % % % 9% 9% % Figure 9 Cardiology Electrophysiology New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time () by Quarter QEII Health Sciences Centre, Average Wait Time Standard Wait Time Count Minimum Wait 7 7 Maximum Wait % Within Standard % % % % % % % % Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait 7,,9 % Within Standard % % % % % 9% % 9% The wait times for the Cardiac Rehabilitation Program are above the recommended standard for the semi-urgent and the non-urgent triages as indicated in the following graphs. Figure Cardiac Rehabilitation Program New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time () by Quarter QEII Health Sciences Centre, - Average Wait Time Standard Wait Time Count 9 Minimum Wait 9 7 Maximum Wait 9 % Within Standard 7% % % % % % 7% % Figure Community Cardiovascular Hearts in Motion Average Wait Time () by Quarter Capital Health, - 7 Average Wait Time Standard Wait Time Count Minimum Wait 7 9 Maximum Wait % Within Standard % % % 9% % % 7% % Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard % % % % % % % 7% Department of Medicine Compendium of Divisional Activity - division of cardiology

13 Diagnostic Laboratories / Technical Procedures There were 9, Electrocardiograms (ECG s) performed during the fiscal year. Figure Electrocardiograms QEII Health Sciences Centre, 9 -, Figure Wait Times for Outpatient Exercise Stress Testing QEII Health Sciences Centre, - 9 There were,9 echocardiograms performed at the QEII, DGH and Cobequid sites in. The wait time for an elective echocardiogram at the end of March was weeks compared to the recommended standard of weeks. Figure, 7,,,79,7 9, eeks # We Echocardiograms Performed Capital Health, 9 -,, grams # Electrocardio,,, Source: MUSE Database There were,9 stress tests performed during. Breakdown by type of test is shown in the graph below. Figure Stress Tests By Type QEII Health Sciences Centre 9 -, 7,,,, Stress Tests #,,, Rehab MIBI Nuclear,,,, 977 Stress,,7,,99, Total 7,9 7, 7, 7,,9 Source: MUSE Database Figure 7 Wait Times for Nuclear Stress Testing QEII Health Sciences Centre, - eks # We Average Standard Average Standard ardiograms # Echoca,,,,, DGH,9,99,,,9 QEII,, 9,,9 9, Total,,,,,9 QEII total includes Cobequid Note: Echocardiograms performed at DGH are done by Fee for Service physicians. Only those under QEII figure are read by DOM Cardiologists with the AFP. Source: Echo Database Figure 9 Elective Echocardiograms Average Wait Time () by Quarter Capital Health, - Average Wait Time Standard Wait Time Count,,79,,,,,, Minimum Wait Maximum Wait,9,,,,,,, % Within Standard % 7% 7% % % 7% 7% % Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY

14 Figure Urgent Echocardiograms Average Wait Time () by Quarter Capital Health, - Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard % 9% % 9% 7% % 7% 7% Figure Dobutamine Echocardiograms Average Wait Time () by Quarter Capital Health, - s D 7 Average Wait Time Count 9 9 Minimum Wait 9 Maximum Wait 9 9 Figure Wait Times for Ambulatory ECG (Holter Monitoring) QEII Health Sciences Centre, - Weeks # W Average Standard Figure Stress Echocardiograms Average Wait Time () by Quarter Capital Health, - In there were,7 Holter monitors performed. The wait time for Holter monitoring at the end of March was weeks compared to the recommended standard of weeks. In there were, loops done with a wait time of 9 weeks at the end of March. Figure D Figure Ambulatory Monitoring - Holter Volumes QEII Health Sciences Centre, 9 -,, Ambulatory Monitoring - Loop Volumes QEII Health Sciences Centre, 9 -,,,,7,,,,, Average Wait Time Count Minimum Wait.... Maximum Wait 97 rs # Holter,,,9,9,,9,7 # Loops,, Source: JEMS Source: MUSE Database Department of Medicine Compendium of Divisional Activity - division of cardiology

15 Figure Wait Times for Ambulatory ECG (Loop Recording) QEII Health Sciences Centre, - Weeks # W Pacemaker / Device (AICD) Clinic A pacemaker clinic was initiated at Dartmouth General during 9-. The combined total pacemaker visits from both sites is slightly above the total for the previous year. Technological advances now enable patients to be followed remotely via telephone lines for defibrillator monitoring, which is more convenient for patients. In,9 registrations for remote transmission monitoring were tracked. Figure 7 Figure Wait Times for Inpatient Pacemaker Insertion QEII Health Sciences Centre, - ays # D Average Standard Ambulatory Monitoring - Pacemaker Visits Capital Health, 9 -, 7,,, /Surgery Data M J J A S O N D J F M isits # V,,, Figure 9 Wait Times for Outpatient Pacemaker Insertion QEII Health Sciences Centre, DGH QEII,,,,,9 Total,,7,,, # /Surgery Data Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY

16 The wait for inpatient pacemaker insertion is days and AICD insertion is day. The wait is days for outpatient pacemaker and days for outpatient AICD implant. Figure Pacemaker Implants QEII Health Sciences Centre, - Volume Replace BiV Replace non-biv 9 9 New BiV New non-biv 9 9 Total Figure Wait Times for Inpatient AICD Insertion QEII Health Sciences Centre, M J J A S O N D J F M ays # D /Surgery Data Figure Figure Automatic Implantable Cardiovascular Defibrillator (AICD) Implants QEII Health Sciences Centre, - Volume V 7 Replace BiV 9 Replace non-biv 7 7 New BiV New non-biv 9 Total 7 7 Source: Paceart Source: Paceart Figure Automatic Implantable Cardioverter Defibrillator (AICD) Registrations QEII Health Sciences Centre, 9 -, ations # Registra,,,,,, Wait Times for Outpatient AICD Insertion QEII Health Sciences Centre, - # # /Surgery Data Remote Transmissions,,,,9 Visits,9,,797,9,9 Total,9,,,, Department of Medicine Compendium of Divisional Activity - division of cardiology

17 Cardiac Catheterization Laboratory Procedures Cardiac Catheterization volumes have decreased slightly with,7 performed in by Cardiologists.,77 percutaneous coronary interventions (PCI s) were performed which represents a decrease compared to the previous year. Figure Cardiac Catheterization Volumes QEII Health Sciences Centre 9 -, Figure 7 Primary PCI QEII Health Sciences Centre, 9 - PCI # Primary P 7 9 Figure 9 Cardiology Wait Times Urgent Percutaneous Coronary Intervention (PCI) QEII Health Sciences Centre, - # , heterizations # Cath,, Source: CVIS Average Standard, Radiologists,79,7,7,, Cardiologists,9,,,7,7 Total,,,,, Source: TomCat Figure Percutaneous Coronary Intervention (PCI) Volumes QEII Health Sciences Centre, 9 -, # PCI,,,,79,99,7,,77 Figure Call Backs Capital Health, Source: CVIS cases # call back c Figure Cardiology Wait Times Semi-Urgent Percutaneous Coronary Intervention (PCI) QEII Health Sciences Centre, - # Average Standard Source: TomCat Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY 7

18 Figure Cardiology Wait Times Elective Percutaneous Coronary Intervention (PCI) QEII Health Sciences Centre, - 7 ys # Da Figure Cardiology Wait Times Urgent Cardiac Catheterization QEII Health Sciences Centre, - # Figure Cardiology Wait Times Elective Cardiac Catheterization QEII Health Sciences Centre, - # Standard Average /CVIS Average Standard /CVIS Average Standard Figure Figure Outpatient Cardiac Catheterization & PCI Wait List QEII Health Sciences Centre, - # Patients # Cardiology Wait Times Semi-Urgent Cardiac Catheterization QEII Health Sciences Centre, - ays # Da /CVIS /CVIS Standard Average Department of Medicine Compendium of Divisional Activity - division of cardiology

19 Electrophysiology Laboratory Procedures Figure Outpatient Wait Times for Urgent EP + Ablation QEII Health Sciences Centre, - # Weeks Average Standard Figure Electrophysiology Studies (EPS) + Ablation Performed QEII Health Sciences Centre, 9-7 lation # EPS + Ab Source: EPS Lab EPS/Ablation EPS Open Heart Surgery Wait Times Figure 9 Cardiac Open Heart Surgery Wait Times In Hospital Urgent Category QEII Health Sciences Centre, - M J J A S O N D J F M Note: Data unavailable for Feb/Mar. This metric switched to Median and separated into CABGS and VALVES in # D CABGS (Median) VALVES (Median) Standard Figure 7 Figure 7 Outpatient Wait Times for Elective EP + Ablation QEII Health Sciences Centre, - # Weeks Standard Average Cardiac Open Heart Surgery Wait Times Semi-Urgent Category QEII Health Sciences Centre, Note: Data unavailable for Feb/Mar. This metric switched to Median and seperated into CABGS and VALVES in. eeks # We Average CABGS (Median) VALVES (Median) Standard Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY 9

20 Figure 7 Cardiac Open Heart Surgery Wait Times Scheduled Category QEII Health Sciences Centre, Weeks # W Note: Data unavailable for Feb/Mar. This metric switched to Median and seperated into CABGS and VALVES in. Patient Residency Distribution of patient residency is shown in figures 7-7. This reflects our dual role as the Atlantic cardiac referral centre and the major secondary care centre for Capital Health..% of CCU,.% of IMCU, 9.% of ward patients and.9% of outpatients were from the Capital Health District. Figure 7 HI. Coronary Care Unit Inpatient Admissions Distribution of Patient Residency by Health District QEII Health Sciences Centre, - Figure 7 HI. IMCU Nursing Unit Inpatient Admissions Distribution of Patient Residency by Health District QEII Health Sciences Centre, - Cape Breton: Guysborough Antigonish Strait: Pictou County: Cumberland: Colchester East Hants: Annapolis Valley: South West Nova: Capital District: Average CABGS (Median) VALVES (Median) Standard Cape Breton: 9 Guysborough Antigonish Strait: 7 Pictou County: South Shore: Out of Province: NB, NF, PEI: 9 Cumberland: Colchester East Hants: Annapolis Valley: Capital District: Figure 7 South West Nova: South Shore: Out of Province: NB, NF, PEI: 7 Cardiology General Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, - Figure 7 HI. IMCU Nursing Unit Inpatient Admissions Distribution of Patient Residency by Health District QEII Health Sciences Centre, - Guysborough Antigonish Strait: Cape Breton: Cape Breton: 99 Guysborough Antigonish Strait: Pictou County: 7 Cumberland: Colchester East Hants: 7 Annapolis Valley: South West Nova: 9 South Shore: Out of Province: 7 Capital District:,97 Pictou County: 77 NB, NF, PEI: 7 Cumberland: Colchester East Hants: Capital District: Annapolis Valley: South West Nova: South Shore: NB, NF, PEI: Out of Province: Department of Medicine Compendium of Divisional Activity - division of cardiology

21 Figure 7 Cardiac Devices Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, - Guysborough Antigonish Strait: 7 Pictou County: Cumberland: Colchester East Hants: Annapolis Valley: South West Nova: 7 South Shore: Out of Province: Cape Breton: NB, NF, PEI: 7 Capital District:, Education Postgraduate Medical Education The Residency Training Program in Adult Cardiology at Dalhousie University continues to be recognized as one of the best in the country, thanks to the high quality of teaching and support provided by all faculty. Three residents completed their training at the end of : Dr. Alex MacLean who is now practicing in Dartmouth, NS Dr. Mousa Al-Harbi who has completed the first of a year Electrophysiology Fellowship, and Dr. Colin Yeung who has just completed a Fellowship in Cardiac Rehabilitation and will be going on to do a second Fellowship in Preventative Cardiology at the Mayo Clinic in Rochester. Our resident complement is currently at and will remain so for the upcoming - academic year. Dr. Ciorsti MacIntyre, Dr. Sanjog Kalra, and Dr. Faisal Al-Ghamdi will be graduating this year and moving on to fellowships in Electrophysiology (Boston), Interventional (Toronto) and Echo/CHF (Edmonton), respectively. rather a lecture or formal teaching which occurs daily through the week. Monday morning is Cardiology Grand Rounds which are presented often by residents and frequently by attending staff. These are teleconferenced across the Maritimes. Monday afternoon once per month is Journal Club, co-organized by Dr. Chris Gray and the Chief Resident. Wednesday mornings are core academic topics in Adult Cardiology (taken from the Royal College Objectives document), Thursday morning there is Bedside Teaching and/or Hemodynamics Rounds, and Friday morning there are rotating topics in Cardiac Imaging, Interventional Cardiology and Research. Friday at noon is regular ECG teaching and/or exam prep sessions. There are Subspecialty Fellowship Training Programs within our Division which continue to flourish Electrophysiology Program under the leadership of Dr. Chris Gray, Interventional Cardiology under the leadership of Dr. Hussein Beydoun, and Echocardiography under the leadership of Dr. Robbie Stewart. Each of these programs are becoming Royal College Accredited Diploma Programs on a national level. The various Subspecialty Program Directors locally will need to submit our Dalhousie documents to the Royal College in the near future. This year additionally Dr. Nick Giacomantonio supervised a fellow in Cardiac Rehabilitation (Dr. Colin Yeung). Joining our resident group in July will be Drs. Andrew Moeller and Jordan Webber from Dalhousie, and Dr. Adam (A.J.) Howes from Memorial University of Newfoundland. We were very pleased with the quality of applications and applicants for our Cardiology spots in and have been approved for a total of funded CaRMS spots over years. The academic program for Adult Cardiology continues to be strong and vibrant, thanks in a large part to the teaching efforts of Division members across all disciplines. There continues to be no defined academic half-day, but The th Annual Combined Cardiology/Cardiac Surgery/ Cardiac Basic Science Research Day was held on May th. This was well attended and well received. Three cardiology residents were represented with posters/oral talks, and several cardiology attendings were involved as well. Attendance from Division members was quite good. There continues to be a chronic issue with inadequate space for resident learners in the Ambulatory Care Clinic. A committee has been struck to look at utilization of space. Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY

22 Undergraduate Teaching This was another successful year of the Metabolism II Block, a second year medical student rotation, which includes Cardiology, Nephrology and Respirology. Evaluations of the units were strong. Members of the division involved in providing lectures for the unit include: Drs. Miroslaw Rajda, Brian Clarke, Robbie Stewart, Sarah Ramer, Bruce Josephson, Chris Gray, Martin Gardner, John Sapp, Richard Lodge, and Michael Love. Tutorials were supervised by the following physicians: Drs. Chris Gray, Martin Gardner, Hussein Beydoun, Helen Curran, Chris Koilpillai, Richard Crowell, and Tony Lee. Laboratory components were performed by the following physicians: Drs. Simon Jackson, Brian Clarke, Alex MacLean, Richard Lodge, Hussein Beydoun, Robbie Stewart, and Richard Crowell. Clinical Skills teaching was performed by many members of the division but a special thanks goes to Dr. Miroslaw Rajda who performed several lectures on the cardiac physical exam and auscultation of heart sounds. The Cardiology IMCU Teaching Service continued to get good feedback from undergraduate medical trainees. Medical students can also do their core in-patient rotation on Ward. on the Green Team Teaching Service. The structured Cardiology lecturers have gotten extremely good evaluations from learners. The two week ambulatory care rotation underwent restructuring in which a more organized schedule was created. This allowed for better preparation for staff members attending in clinic and a dedicated room for medical students during the rotation. Students spend the majority of their time in General Cardiology clinics, but also can get exposure to the Connective Tissue Clinic, stress testing, Heart Function Clinic, and the Cardiac Rehabilitation Centre. Finally a Core Cardiology lecture on Acute Coronary Syndromes has been added to the Core Internal Medicine Teaching Schedule, the first time in many years that a Cardiology lecture has been part of that teaching schedule. Continuing Medical Education Cardiologists are active in the provision of continuing medical education. In Cardiologists presented lectures at local, national and international venues. Cardiologists also participated in continuing medical education events. Research To improve and facilitate research productivity in the Division of Cardiology, several changes were made in. Dr. Martin Gardner was appointed the Director of Research for the Division of Cardiology and has been offered a seat on the Department of Medicine Research Committee. Dr. Ratika Parkash has been appointed as Associate Director and Ms. Debbie Wright has been hired as the Research Manager. With clear research infrastructure and support from the Research Management Committee of the division; we have begun consolidating research accounts, have been working to negotiate contracts, and been working with the Centre for Clinical Research to develop a fair and transparent process for all research activity. These processes will be documented and available in a standard operating procedure manual which is under development. The achievements of our researchers have been highlighted by a once a month presentation by each research group to the entire Division and all interested research and clinical staff that work within Cardiology and the Heart Health Program. These have been extremely well-received and have helped the larger group to understand the accomplishments of our busy research groups. Research activity in Cardiology has increased as this area has become a major concern of the leadership and membership of the division. Those with major research roles have succeeded in grant funding, national and international recognition of their work. Many division members without a major research role have started research activities and been successful in national presentations and publications. The division decided to hire a research manager to assist investigators and research personnel with financing, resource needs and institutional requirements. Department of Medicine Compendium of Divisional Activity - division of cardiology

23 Cardiovascular Rehabilitation and Prevention Outcomes Research and Education Under the research and clinical direction of Dr. Nicholas Giacomantonio, the Community Cardiovascular Hearts in Motion program (CCHIM) originated as a $.M research project beginning in. Since that time, over, patients have been referred to the program with established coronary disease, peripheral vascular disease, non-disabling stroke or TIA, or high risk primary prevention. This makes the program unique amongst cardiac rehabilitation programs anywhere in Nova Scotia or Canada as it is not a singular vascular disease program but expands the continuum of care in atherosclerotic cardiovascular disease. Most recently, data from Hearts in Motion has demonstrated sustained and durable risk factor reduction across the majority of risk factors in patients who attend the program and are followed up to one year. This has translated to a mortality reduction at an average of only two years follow up in patients with established cardiovascular disease who attend the program as compared to matched control patients who have not attended. This benefit comes at no significant additional cost to the healthcare system. A statistically significant mortality advantage for high risk primary patients is also observed at Hearts in Motion as compared to case matched controls. Collectively, these data have led to permanent funding of the physical sites managed by a single team in Lower Sackville, Dartmouth Sportsplex, and Spryfield as of May. An evening program has begun at the Mumford Site and collaborative efforts with the more traditional hospital based Health in Motion Program is underway with plans to expand program offerings to more diverse populations such as those with connective tissue disease, and patients with atrial fibrillation as a primary diagnosis. The research platform established by Hearts in Motion is continuing to expand with projects in translational research, formal evaluation of patients with non-disabling stroke to include cognitive functioning, patients with inflammatory diseases as rheumatoid arthritis who are at otherwise moderate risk cardiovascular disease by traditional risk tools, and the virtualization of the entire Hearts in Motion platform in an effort to bring this quality program away from the bricks and mortar and directly into the family doctors offices. Most recently, Dr. Giacomantonio has been successful in acquiring a $.M grant with colleagues across the country that will look at risk change and outcomes of patients who are survivors of, or bear high risk for cancer. The project, known as ACCELERATION, will enroll, patients across the country and is heavily invested in behavior change as well as development of a digital platform to track and impact on positive behavior changes and risk factor reduction. In March/, Dr. Giacomantonio, along with Dr. Arora in Winnipeg and Dr. Hassan in New Brunswick were awarded a $, grant to evaluate the potential benefits of PreHab on patients who are moderately frail and awaiting cardiovascular surgery. Local Co-PI with Dr. J.F. Legare and the CV Surgery Group will begin a very strong path to future outcomes oriented research in such patients. The first research fellow in cardiac rehabilitation at Capital Health and Dalhousie University finished a successful academic year with acceptance of his abstract on CCS Driven quality indicators for cardiac rehabilitation and prevention. Dr. Colin Yeung has been accepted for a second fellowship year in Cardiac Rehabilitation at the Mayo Clinic in Minnesota. There is a strong desire and hope that research fellow activity will continue in the future. Dr. Giacomantonio s direction, referred to as Vision is to have appropriate and progressive cost effective provincial programming in cardiac Rehabilitation and Prevention across the entire province as well as virtualization of the Hearts in Motion model to allow access to the majority of Nova Scotians who will never be able to attend a physical plant because of geographical, patient centered, and resource limited reasons despite their established cardiovascular disease or high risk features. Without such vision and progression, such patients will continue to receive disparate and substandard care. Finally, all of this activity and education is directed and displayed through public advocacy via the HeartLand Tour (HLT). Now in its eighth year, the HLT continues to grow and proclaim the excess burden of risk across the province while promoting and preaching the ways to change through prevention, well developed programs and community effort. In, the HLT team will be joined by the Minister of Health for rides in Yarmouth and Halifax as well as the inclusion of a population health research study with one of the Dalhousie Medical Students (Brett Barro) involved with the tour this year. Brett was also the successful recipient of a research award stipend for $, to complete the study referred to as Do You CARE-AF. The source funding chosen by the Dalhousie Medical Research office comes from the newly developed Dr. Magdy N. Basta Endowed Fund. Visit HeartLandTour.ca for complete details of the tour and study. The Division generated $,,7 in research grants ($,,7) and industry contracts ($,9) during. Division members provided referee or editorial services to journals/granting agencies in. There were 7 peer reviewed, refereed papers and articles published by division members in. There were abstracts and research presentations. The Division supervised residents in directed research projects. Department of Medicine Compendium of Divisional Activity - division of CARDIOLOGY