Compendium of Divisional Activity

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1 Compendium of Divisional Activity

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3 Department of Medicine Compendium of Divisional Activity April 1, March 31, 213 Division of Cardiology 1 Physician Resources 2 Division Highlights 2 Public Education 3 Quality Patient Safety 4 Issues of Appropriateness of Care 4 Clinical Services 5 Emergency Coverage 5 Inpatient Services 5 Bed Days and Occupancy 6 Tertiary Care 8 Inpatient Consultations 8 Ambulatory Care 9 Outpatient Wait Times 1 Diagnostic Laboratories / Technical Procedures 12 Pacemaker/Device (AICD) Clinic 14 Cardiac Catheterization Laboratory Procedures 16 Electrophysiology Laboratory Procedures 18 Open-Heart Surgery Wait Times 19 Patient Residency 2 Education 21 Research 22 Administration 24 Division of Clinical Dermatology & Cutaneous Science 27 Physician Resources 28 Our Patient Care 28 Our Teaching 28 Divisional Highlights 28 New Programs and Initiatives 28 Work for the Nova Scotia Department of Health and Wellness 29 Quality and Patient Safety 29 Shadow Charts 29 Public Education 29 Clinical Services 29 Emergency Coverage 3 Inpatient Services 3 Inpatient Consultations 3 Ambulatory Care 3 Telemedicine Clinics 33 Special Service Commitments 34 Medical Day Unit 35 Ambulatory Care Wait Times 35 Clinic No Shows 37 Patient Demographics 38 Education 39 Research 4 Administration 4 Division of Digestive Care & Endoscopy 41 Physician Resources 42 Emergency Coverage 42 Inpatient Services 43 Inpatient Consultations 43 Ambulatory Care Clinics 44 Endoscopy 44 Ambulatory Care Wait Time 45 Clinic No Show 46 Medical Day Unit 46 Distribution of Patients by Age 47 Distribution of Patients by District 47 Education 47 Research 48 Division of Endocrinology & Metabolism 49 Physician Resources 5 Divisional Highlights 5 New Programs and Initiatives 5 Work for the Nova Scotia Department of Health and Wellness 5 Quality and Patient Safety 5 Shadow Charts 5 Public Education 5 Clinical Services 51 Emergency Coverage 51 TABLE OF CONTENTS DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY TABLE OF CONTENTS i

4 TABLE OF CONTENTS Inpatient Services 51 Inpatient Consultations 51 Ambulatory Care QEII Health Sciences Centre 52 Special Service Commitments 57 Diabetes Management Centre 57 Ambulatory Care Wait Lists 58 Clinic No Shows 6 Distribution of Patients by District 6 Distribution of Patients by Age and Gender 61 Education 61 Research 62 Administration 62 Education 73 Research 73 Administration 74 Division of Geriatric Medicine 75 Physician Resources 76 Division Highlights 76 Improvements to Patient Care 76 Quality Patient Safety 76 New Programs, Partnerships & Innovations 76 Work for the Nova Scotia Department of Health and Wellness 77 Efforts to Reduce Average Length of Stay 77 New Programs, Partnerships and Innovations 9 Work for the Nova Scotia Department of Health and Wellness 91 Quality Patient Safety 91 Average Length of Stay 91 Public Education 91 Clinical Services 91 Emergency Coverage 91 Inpatient Services (General Hematology and BMT) 92 Blood and Marrow Transplant Program (BMT) 93 Inpatient Consultations 93 Ambulatory Care 94 Special Service Commitments 94 Division of General Internal Medicine 63 Public Education 77 Wait Times and Outpatient Throughput 95 Physician Resources 64 Divisional Highlights 64 New Programs and Initiatives 64 Quality and Patient Safety 65 Average Length of Stay 65 Clinical Services 65 Inpatient Consultations 66 Ambulatory Care 66 Ambulatory Care Dartmouth General Hospital (DGH) 69 Ambulatory Care Cobequid Community Health Centre (CCHC) 69 Issues of Appropriateness of Care 77 Emergency and MTU Coverage 77 Inpatient Services 78 Inpatient Consultations 82 Inpatient Services Wait Times 84 Ambulatory Care 84 Ambulatory Care Wait Times 85 Patient Residency 85 Education 86 Research 87 Administration 87 Medical Day Unit (MDU) 97 Education 98 Research 99 Administration 99 Division of Infectious Diseases 11 Physician Resources 12 Divisional Highlights 12 New Programs and Initiatives 13 Work for the Nova Scotia Department of Health and Wellness 13 Quality and Patient Safety 14 Ambulatory Care Wait Lists 69 Division of Hematology 89 Efforts to Eliminate Shadow Charts 15 No Shows 71 Distribution of Patients by District 72 Physician Resources 9 Divisional Highlights 9 Public Education 15 Issues of Appropriateness of Care 15 ii DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY TABLE OF CONTENTS

5 Clinical Services 16 Emergency Coverage 16 Inpatient Services 16 Inpatient Consultations 16 Telephone Consultations 17 Ambulatory Care 17 Wait Times 11 Education 123 Research 123 Administration 124 Division of Nephrology 125 Our Patient Care 126 New Programs, Partnerships & Innovations 126 Division of Neurology 137 Physician Resources 138 Division Highlights 138 Clinical Activity 139 New Programs, Partnerships and Innovations 139 Work for the Nova Scotia Department of Health and Wellness 14 TABLE OF CONTENTS Patients Referred but Not Seen 111 Our Team 126 Quality & Patient Safety 141 Clinic No Shows 111 Patient Demographics 112 Education 112 Research 113 Administration 114 Division of Medical Oncology 115 Physician Resources 116 Divisional Highlights 116 New Programs, Partnerships & Innovations 116 Work for the Nova Scotia Department of Health and Wellness 116 Quality and Patient Safety 116 Public Education 117 Clinical Services 117 Work for the Nova Scotia Department of Health and Wellness 127 Quality Patient Safety 127 Shadow Charts 127 Average Length of Stay 127 Clinical Activities & Services 127 Issues of Appropriateness of Care 127 Service Delivery Summary 127 Inpatient Services 128 Dialysis 13 Ambulatory Care 131 Medical Day Unit 132 Triage Guidelines and Wait Times 132 Transplant 133 Renal Transplant Wait List Patient Evaluations 134 Shadow Charts 141 Average Length of Stay 142 Public Education 142 Issues of Appropriateness of Care 142 Clinical Services 142 Emergency Coverage 142 Inpatient Services 143 Inpatient Consultations 144 Ambulatory Care 144 Neuro-diagnostic Laboratories 147 Patient Residency 148 Education 149 Research 151 Administration 151 Emergency Coverage 117 Education 135 Division of Palliative Medicine 153 Inpatient Services 117 Inpatient Demographics 118 Inpatient Consultations 119 Ambulatory Care 119 Medical Day Unit 122 Research 135 Administration 136 Division Highlights 154 Physician Resources 154 New Programs, Partnerships & Innovations 154 Work for the Nova Scotia Department of Health and Wellness 155 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY TABLE OF CONTENTS iii

6 TABLE OF CONTENTS Quality Patient Safety 155 Issues of Appropriateness of Care 155 Clinical Services 155 Inpatient Services 16 Education 162 Research 174 Administration 174 Division of Respirology 175 Physician Resources 176 Physician Resources 185 Clinical Services 185 Emergency Coverage 185 Inpatient Services 185 Inpatient Consultations 186 Research 162 Clinical Services 176 Ambulatory Care 186 Administration 162 Emergency Coverage 176 Wait Times 188 Division of Physical Medicine & Rehabilitation 163 Physician Resources 164 Our Patient Care 164 New Programs, Partnerships & Innovations 165 Work for the Nova Scotia Department of Health and Wellness 166 Quality Patient Safety 166 Average Length of Stay 166 Public Education 167 Issues of Appropriateness of Care 167 Emergency Coverage 167 Clinical Services 167 Inpatient Services 168 Inpatient Consultations 17 Ambulatory Care 171 Inpatient Services 176 Inpatient Consultations 176 Ambulatory Care 177 Sleep Studies 177 Technical Procedures 178 Bronchoscopies 178 Pulmonary Arterial Hypertension 178 Triage Guidelines & Wait Times 179 Medical Day Unit 18 Clinic No Shows 18 Discharges 18 Distribution of Patients by Age 181 Distribution of Patients by District 181 Education 181 Research 182 Administration 182 Clinic No Shows 189 Distribution of Patients 19 Education 19 Research 191 Administration 192 Triage Guidelines & Wait Times 172 No Show 173 Distribution of Patients by Age 173 Distribution of Patients by District 173 Education 173 Division of Rheumatology 183 Division Highlights 184 New Programs, Partnerships & Innovations 184 Quality Patient Safety 184 Issues of Appropriateness of Care 185 iv DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY TABLE OF CONTENTS

7 Division of Cardiology DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 1

8 DIVISION OF CARDIOLOGY Physician Resources The physician resources consist of 33 members with a total of FTEs when at full complement. There are additionally 2 full-time fee-for-service cardiologists at the Dartmouth General Hospital Site who are affiliated with the Division of Cardiology. The Division of Cardiology provides exemplary state-ofthe-art care including primary care to the patients of Halifax Regional Municipality along with secondary and tertiary care to the entire Provinces of Nova Scotia and Prince Edward Island. Quaternary care is provided to the Atlantic Provinces for complex tertiary care programs such as Cardiac Transplantation, Structural Heart Disease, Advanced Cardiac Arrhythmia and others. The Division of Cardiology is very excited to welcome Dr. Helen Curran as full-time interventionalist to the Division of Cardiology in 212 after completing a 2 year Interventional Fellowship at the University of Calgary. The Division of Cardiology is also extremely pleased to have Dr. Kim Styles join the Division as a full-time member occupying a locum position for 1 year following the completion of her Echo Fellowship and similarly Dr. Dongsheng Gao joined the Division as a full-time member in a locum position for 1 year filling in for Dr. Magdy Basta who was on medical leave. Division Highlights Patient Care Cardiology continues to be responsible for a total of 82 beds at the Halifax Infirmary, Capital Health. The Cardiology Group provides 24 hour 7 days a week emergency on-call coverage for all in-patients with direct response to the Emergency Department. The in-patient wards of IMCU and 6.2 continue to be extremely busy with 95% occupancy following a length of stay on both the Intermediate Care Unit and the Coronary Care Intensive Unit. The average length of stay at the Intermediate Care Unit is now 3 days. The average length of stay in the Coronary Care Unit is now 3.1 days. The length of stay on the 6.2 unit unfortunately has increased from 7.6 days in to 8.4 days in It is suspected that the cause of this is a higher proportion of elderly patients with complex co-morbidities; however, this will require verification. The Division of Cardiology provides tertiary care for the Province of Nova Scotia in the form of a transfer service where patients are referred from across the Province triaged on a priority basis and brought in according to acuity on a daily basis. The admissions are direct admissions from their home hospital; they undergo necessary investigations and return to home hospital by the following days. In ,23 transfers were accepted by the Division of Cardiology and returned to home hospital in less than 24 hours. Wait times for all invasive, non-invasive and consultative services in Cardiology are tracked compared to national wait times and monitored on a month-to-month basis. All electrodiagnostic non-invasive testing and invasive interventional procedures in Cardiology are provided to both in-patients and out-patients. All wait times and outcomes are tracked and monitored on a regular basis. In , the Division of Cardiology performed 11,652 echoes; a decrease from the previous year due to a reduction in available echocardiographic sonographer technician staff, a situation which has since been rectified. Along with this decrease in the number of echocardiograms that were able to be provided there was an expected increase in wait times for all categories of echocardiograms which exceed national and local standards. Other non-invasive electrodiagnostic tests include: stress tests, loop recorder, ECG, pacemaker assessments and device assessments. The volumes in these non-invasive electrodiagnostic categories have been stable and plateaued over several years. For there were 7,234 stress tests, 2,249 Holters, 1,48 Loops, 85,276 ECGs, 3,452 device integrations and 3,233 pacemaker visits. Invasive interventional procedural volumes for including the in-patients and out-patients total 4,18 cardiac catheterizations (stable plateau), 1,812 percutaneous coronary interventions of which 21 were primary PCIs for acute myocardial infarctions (heart attacks). There were 357 call-backs in the fiscal year of to the Cardiac Catheterization Laboratories. The Heart Rhythm Laboratory completed 437 procedures a stable plateau for the last several years. In Ambulatory Care there were 33,773 Cardiology Clinic registrations with a 4.9% no-show rate. In September 212 we saw the launch of the new transcatheter aortic valve implantation (TAVI) multi disciplinary program whereby patients who are in need 2 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

9 of an aortic valve replacement but are very high risk for traditional surgery can now be offered a percutaneous option with placement of a transcatheter aortic valve via either a femoral or apical approach in a minimally invasive percutaneous manner. The transcatheter program involves co-operation of interventional cardiologists under the lead of Dr. Najaf Nadeem, cardiovascular surgeons under the lead of Dr. John Sullivan, interventional radiologists under the lead of Dr. Rob Barry, cardiac radiology under the lead of Dr. Alan Brydie and cardiac anesthesia under the lead of Dr. Blaine Kent. The TAVI Program won an Anesthesia Award for Excellence from the Department of Anesthesia, Pain Management and Peri-operative Medicine in March 213. The program has been successful in offering an alternative to medical therapy or extremely high risk surgery for this small but very ill group of complex elderly patients. In the Electrophysiology Heart Rhythm Group won a Quality Award for the Capital Health Heart Rhythm Service s changing to meet the patients needs with the implementation of an out-patient evidence-based assessment protocol which documented improve patient care, decreased length of stay and excellent outcomes. This was awarded at the Quality Summit 213. The Division of Cardiology strives to continue to provide exemplary excellent clinical care leadership in education and research. As the sole provider of diagnostic interventional and surgical cardiac care in the Province of Nova Scotia we work diligently to provide through, effective, appropriate and efficient service to the entire cardiovascular community of the Province of Nova Scotia. Transcatheter Aortic Valve Interventional Program Transcatheter aortic valve interventional (TAVI) Program is an innovative, multidisciplinary initiative developed to treat patients with severe symptomatic aortic valve stenosis who are otherwise considered at prohibitive/high risk for conventional surgical aortic valve replacement. This program was developed by Dr. Najaf Nadeem from Interventional Cardiology and Dr. John Sullivan from Cardiac Surgery. They collaborated with a multidisciplinary team comprising of cardiologists, cardiac surgeons, radiologists, anesthetists and support staff. Following formal approval by Nova Scotia Department of Health and Wellness, the TAVI Program was inaugurated in September 212. The TAVI team has screened more than 1 patients. From September 212 and July 213, they performed 26 procedures with good results, and 1% survival at 3 days. Following successful results; the Program is approved to continue in second year with anticipated growth in clinical volumes. Public Education Under the research and clinical direction of Dr. Nicholas Giacomantonio, the Community Cardiovascular Hearts in Motion program (CCHIM) originated as a $1.5 M research project beginning in 26. Since that time, nearly 2, 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. Data from CCHIM is rich and diverse and has been presented locally, nationally, and internationally including a recent honorable mention during presentation at EuroPrevent, Rome, Italy, April 213. 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 3 physical sites managed by a single team in Lower Sackville, Dartmouth Sportsplex, and Spryfield as of May 213. DIVISION OF CARDIOLOGY 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 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 3

10 DIVISION OF CARDIOLOGY 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. (Referred to as vhim) Most recently, Dr. Giacomantonio has been successful in acquiring a $2.4 million 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. Finally, the first research fellow in cardiac rehabilitation at Capital Health and Dalhousie University begins in the academic year. There is a strong desire and hope that this will continue annually and that progressive expansion of Hearts in Motion with translational outcomes research will occur in Capital Health and across the Province of Nova Scotia as Dr. Giacomantonio is working toward provincial programming. Quality Patient Safety Morbidity and Mortality Rounds were performed at the end of each resident rotation, 13 over the year, and led by the CCU senior resident. The focus is on reviewing controversial cases or those with learning value in a setting with multidisciplinary health care professionals. Significant morbidities and mortalities are reviewed with a goal towards creating a culture of learning from mistakes and of improving system processes. There are also further initiatives to have bi-annual M & M Rounds with involvement of Cardiac Surgery. This year there was a new addition to the series of Quality Assurance Rounds. There are 2 Combined Morbidity and Mortality Rounds that were co-hosted by Cardiology and Cardiovascular Surgery. The rounds were very well attended and they received excellent feedback. The first of these rounds focused on timely revascularization of patients with acute coronary syndromes. Two cases were reviewed. Several issues were identified and further follow-up meetings were occurring to better facilitate the care of this high risk patient group. The next Combined Mortality and Morbidity Rounds focused on the topic of endocarditis. Again, 2 clinical cases were presented by senior residents and there was great discussion around the management of these cases. Some of the more recent literature looking at early surgery in certain patients with endocarditis was reviewed in addition to surgical treatment of patients with right-sided endocarditis. There was general agreement that prompt transthoracic and transesophageal echoes should be performed in any patients in which cardiac surgery was being considered. In addition, patients with large left heart valve vegetations should be considered for early surgery to reduce their risk of thromboembolism. Issues of Appropriateness of Care The Division of Cardiology and Cardiovascular Surgery have a long >3 years history of Combined Peer review Rounds which occur weekly. At this conference all potential candidate cases are reviewed by both Cardiovascular Surgery and Cardiology for appropriateness of case for revascularization and the merits of either traditional open heart surgery (CABG) vs. percutaneous coronary intervention (PCI) are reviewed for most appropriate intervention. All cases are triaged according to national standards to the appropriate wait list category. Wait lists are monitored and auctioned monthly. 4 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

11 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 Emergency Coverage Cardiologists provide 24 hour, 7-day/week emergency and on-call coverage for patients in Capital Health. Subspecialty 24 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 24 hour 7-day/week attending / on-call physician coverage provided to all inpatient services. To maximize bed efficiency, cardiology inpatients are evaluated and managed every day. The following chart shows the bed allocations for Cardiology. Table 1 Unit/Designation # Beds CCU (6.4) 1 Ward (6.2) 37 IMCU (6.1b) - Transfer 14 4 Total Inpatient Beds 65 Chest Pain Cardiac Day Unit (CDU-6.1b) 2 15 Total Beds 82 DIVISION OF CARDIOLOGY Pacemaker/Device Clinic Heart Function Clinic Cardiac Health in Motion (Cardiac Rehab) Cardiac Transplant Program Adult Congenital Heart Disease Emergency Liaison, Early Discharge Clinic Connective Tissue Clinic DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 5

12 DIVISION OF CARDIOLOGY Bed Days and Occupancy Figure 1 HI 6.4 Coronary Care Unit Average Bed Day Utilization by Fiscal Year 4,5 4, 3,5 3, Figure 3 HI 62 Nursing Unit Average Bed Day Utilization by Fiscal Year 16, Bed Days 14, 12, 1, 8, 6, Figure 5 HI 61 IMCU Nursing Unit Occupancy Rate by Fiscal Year 1% Percent Occupancy 9% 8% 7% 6% 5% 4% 93.7% 92.9% 91.8% 94.7% 94.1% Bed Days 2,5 2, 4, 2, 3% 2% 1,5 1, On Ser Used 2,442 2,674 2,86 3,163 3,58 Avail 2,874 3,178 3,44 3,646 3,872 Figure Bed Days Used 12,475 12,446 12,66 12,876 12,711 Avail 13,48 13,218 13,399 13,451 13,336 Figure 4 HI 6.4 Coronary Care Unit Inpatient Bed Occupancy Rate by Fiscal Year 1% 1% % Figure 6 HI 62 Nursing Unit Occupancy Rate by Fiscal Year 11% HI 61 IMCU Nursing Unit Average Bed Day Utilization by Fiscal Year 7, Bed Days 6, 5, 4, 3, Percent Occupancy 9% 8% 7% 6% 5% 4% 3% 2% 85.9% 84.7% 84.% 87.9% 84.5% Percent Occupancy 1% 9% 8% 7% 6% 5% 4% 3% 2% 95.6% 94.2% 94.1% 95.7% 95.3% 2, 1, Bed Days Used 5,766 5,619 5,581 5,694 5,665 Avail 6,152 6,49 6,82 6,14 6,23 1% % % % DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

13 Admissions and transfers in to CCU, IMCU and Unit 6.2 are shown. As per discussion with Divisional administration the logic was revised in 29/1 so that any transfers from EMERGENCY are classified as Admissions. Transfers refer to patients from other QEII units. 866 patients admitted (and 253 patients transferred from other units) to coronary care in 212/13 for a total of 1,119 admissions. Figure 7 Figure 9 HI 62 Nursing Unit Inpatient Admissions and Transfers In by Fiscal Year 2,5 Admissions and Transfers 2, 1,5 1, 5 ALOS on Unit 6.2 has increased with an ALOS for 22/13 of 8.4 days compared to 7.6 days the previous year. Figure 11 HI 61 IMCU Nursing Unit Average Stay (Days) by Fiscal Year DIVISION OF CARDIOLOGY HI 6.4 Coronary Care Unit Inpatient Admissions and Transfers In by Fiscal Year 1,2 1, Transfer In Admits 1,494 1,487 1,528 1,513 1,281 Total 2,121 2,154 2,197 2,184 1,961 Days 2 1 Admissions and Transfers The introduction of the new multi-disciplinary Heart Health Transcatheter Aortic Valve Implantation Program in September 212 has substantially decreased the length of stay for elderly complex patients requiring aortic valve replacement Figure Transfer In Admits Total ,119 Figure 8 Figure 1 HI 6.4 Coronary Care Unit Inpatient Average Length of Stay (Days) by Fiscal Year 5 HI 62 Nursing Unit Average Stay (Days) by Fiscal Year HI 61 IMCU Nursing Unit Inpatient Admissions and Transfers In by Fiscal Year 2, Days Days Admissions and Transfers 1,5 1, Transfer In Admits 1,573 1,494 1,519 1,583 1,45 Total 1,837 1,84 1,85 1,876 1,83 The Average Length of Stay (ALOS) is shown for the past five fiscal years. In 212/13, the ALOS in CCU decreased to 3.1 days. The ALOS in IMCU decreased to 3. days. The DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 7

14 DIVISION OF CARDIOLOGY Tertiary Care There were 2,23 tertiary care transfers for the fiscal year 212/13 under the direction of Bed Manager, Dr. Ata Quraishi. Fiscal year trending data are shown: Figure 13 Cardiology Tertiary Transfers by Fiscal Year 2,5 2, 2,38 2,192 2,32 2,167 2,23 Figure 15 Cardiology Wait Times for IMCU Transfers from Cath Lab QEII Health Sciences Centre, # Days 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 24 hour, and usually same day consultation service, at the sites of the QEII and for the IWK. 2,917 major consults were provided across all sites in 212/13. # Patients Transferred 1,5 1,.. April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual IMCU-24/48 IMCU-S Standard Figure to 9 9 to 1 1 to to to 13 Source: Approach Database Cardiology Wait Times for Ward Transfers from Cath Lab QEII Health Sciences Centre, Figure Cardiology Wait Times for CCU Transfers from Cath Lab QEII Health Sciences Centre, # Days # Days April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard.6 April M J J A S O N D J F M April M J J A S O N D J F M Ward /48 Ward /48 Standard Ward 6.2-S Ward 6.2-S Standard Source: Manual 8 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

15 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 31,843 registrations for all cardiology clinics in the year 212/13. This is an increase of 2.% from the previous year. There were an additional 2,318 chart checks performed in 212/13 not reported in the following figures. Figure 17 Cardiology Clinics New and Return Ambulatory Care Registrations 35, 3, 25, The following graphs show registration numbers for General Cardiology and Electrophysiology for the past five years. There has been a.5% increase in General Cardiology registrations. Figure 18 General Cardiology New and Return Physician Ambulatory Care Registrations 12, Registrations 1, 8, 6, 4, 2, CodeMissing New 4,545 4,693 4,236 5,6 5,165 Return 4,399 5,223 5,882 5,641 5,41 Total 9,141 1,234 1,328 1,965 11,19 % New 49.7% 45.9% 41.% 46.1% 46.9% Figure 19 Figure 2 Cardiology Congenital Heart Clinic New and Return Ambulatory Care Registrations 8 Registrations CodeMissing New Return Total % New 11.9% 16.3% 16.4% 19.6% 16.2% Figure 21 Cardiac Devices New and Return Ambulatory Care Registrations 7, 6, DIVISION OF CARDIOLOGY Registrations 2, 15, 1, 5, Cardiology Electrophysiology New and Return Ambulatory Care Registrations 3, Registrations 5, 4, 3, 2, CodeMissing 1,312 1,429 2,33 1,844 3,221 New 7,717 8,221 8,774 9,441 8,91 Return 18,559 18,92 2,156 19,92 19,712 Total 27,588 28,57 3,963 31,25 31,843 % New 28.% 28.8% 28.3% 3.3% 28.% Registrations 2,5 2, 1,5 1, 5 1, CodeMissing ,369 New Return 5,141 4,392 4,786 5,337 4,613 Total 5,447 4,948 5,74 6,18 6,33 % New 3.% 3.9% 8.9% 4.4%.8% CodeMissing New Return 1,211 1,195 1,59 1,55 1,291 Total 1,935 2,17 2,384 2,429 2,229 % New 36.5% 39.8% 36.5% 36.1% 38.6% DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 9

16 DIVISION OF CARDIOLOGY Figure 22 Cardiology Pre-Admit New and Return Ambulatory Care Registrations 3, Registrations 2,5 2, 1,5 1, Figure 24 Cardiology Heart Transplant Clinic New and Return Ambulatory Care Registrations 1,2 Registrations 1, Outpatient Wait Times The wait time for new elective outpatient referrals remains stable at 12 weeks and remains above the recommended standard of 6 weeks. Wait times for Urgent and Semi- Urgent referrals have decreased slightly. General Cardiology and Electrophysiology (EP) wait times are now being reported separately. This has helped put additional focus on the resource constraints in EP CodeMissing New 1,556 1,881 2,241 2,318 1,961 Return Total 2,544 2,573 2,584 2,653 2,426 % New 61.2% 73.1% 86.7% 87.4% 8.8% Figure 23 Cardiology Heart Function Clinic New and Return Ambulatory Care Registrations 4, Registrations 3,5 3, 2,5 2, 1,5 1, CodeMissing New Return ,96 Total ,137 % New 4.% 2.8% 2.8% 4.% 3.3% Figure 25 Cardiology New Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 56% 46% 45% 46% 48% 43% 59% 46% Source: PHS Data CodeMissing New Return 2,93 3,462 2,571 2,686 2,8 Total 3,28 3,71 2,894 2,99 2,987 % New 6.6% 5.5% 5.% 4.8% 5.% 1 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

17 Figure 26 Cardiology New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 56% 48% 6% 52% 52% 48% 59% 5% Source: PHS Data Figure 27 Cardiology New Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Wait times for urgent electrophysiology referrals are 2.3 days which is above the standard of 3 days. Figure 28 Cardiology Electrophysiology New Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 13% 13% 8% 1% 22% 17% 1% % Source: PHS Data Figure 29 Cardiology Electrophysiology New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Wait times for non-urgent Electrophysiology referrals remain high at days in compared to the benchmark of 9 days, but is improved slightly compared to the same period last year. Figure 3 Cardiology Electrophysiology New Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait , % Within Standard 31% 24% 25% 33% 45% 46% 35% 32% Source: PHS Data 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. DIVISION OF CARDIOLOGY 2 Average Wait Time Standard Wait Time Count , 849 Minimum Wait Maximum Wait % Within Standard 33% 16% 24% 22% 16% 29% 22% 25% Source: PHS Data Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 13% 26% 22% 24% 1% 21% 2% 24% Source: PHS Data Figure 31 Cardiac Rehabilitation Program New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 33% 29% 2% % % 5% 1% % Source: PHS Data DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 11

18 DIVISION OF CARDIOLOGY Figure 32 Cardiac Rehabilitation Program New Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 64% 68% 4% 4% 74% 85% 83% 51% Source: PHS Data Figure 33 Community Cardiovascular Hearts in Motion Average Wait Time (Days) by Quarter Capital Health, Diagnostic Laboratories / Technical Procedures There were 85,276 Electrocardiograms (ECG s) performed during the fiscal year Figure 34 Electrocardiograms 1, # Electrocardiograms 8, 6, 4, 2, 74,889 76,821 82,866 88,379 85,276 8 to 9 9 to 1 1 to to to 13 Source: MUSE Database In March 29, a quality improvement project was implemented aimed at reducing the wait time for exercise stress tests. This change has helped to improve the utilization of the lab and to reduce the wait times dramatically. Figure 36 Wait Times for Outpatient Exercise Stress Testing QEII Health Sciences Centre, # Weeks Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 17% 2% 14% 4% 1% 16% 1% 9% Source: PHS Data There were 7,234 stress tests performed during Breakdown by type of test is shown in the graph below. Figure 35 Stress Tests By Type QEII Health Sciences Centre , 7, 6, 5, 4, 3, 2, 1, Rehab MIBI Nuclear 1,475 1,264 1,35 1,142 1,26 Stress 5,135 5,184 4,75 5,6 4,899 Total 7,777 7,619 7,2 7,485 7,234 Source: MUSE Database # Stress Tests April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard Figure 37 Wait Times for Nuclear Stress Testing QEII Health Sciences Centre, # Weeks April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

19 There were 11,652 echocardiograms performed at the QEII, DGH and Cobequid sites in The wait time for an elective echocardiogram at the end of March 213 was 34 weeks compared to the recommended standard of 4 weeks. Figure 38 Echocardiograms Performed Capital Health, , # Echocardiograms 12, 1, 8, 6, Figure 4 Urgent Echocardiograms Average Wait Time (Days) by Quarter Capital Health, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 26% 41% 29% 28% 23% 39% 31% 29% Source: PHS Data Figure 42 Dobutamine Echocardiograms Average Wait Time (Days) by Quarter Capital Health, Days Average Wait Time Count Minimum Wait Maximum Wait Source: PHS Data DIVISION OF CARDIOLOGY 4, 2, 8 to 9 9 to 1 1 to to to 13 DGH 2,88 2,913 2,899 3,156 3,156 QEII 8,414 8,522 8,454 9,355 8,496 Total 11,222 11,435 11,353 12,511 11,652 Source: ECHO Database A LEAN initiative was undertaken by the division in 211/12 aimed at improving efficiency of Echocardiography processes. Figure 41 Stress Echocardiograms Average Wait Time (Days) by Quarter Capital Health, Days In there were 2,249 Holter monitors performed. The wait time for Holter monitoring at the end of March 213 was 8 weeks compared to the recommended standard of 4 weeks. Figure 43 Ambulatory Monitoring - Holter Volumes 3, Figure 39 Elective Echocardiograms Average Wait Time (Days) by Quarter Capital Health, Average Wait Time Count Minimum Wait Maximum Wait Source: PHS Data # Holters 2,5 2, 1,5 1, 2,167 2,294 2,391 2,42 2,249 Days Average Wait Time Standard Wait Time Count 93 1,161 1,232 1,526 1,534 1,579 1,344 1,368 Minimum Wait 1 3 Maximum Wait 1,464 1,281 1,239 1,473 1,491 1,421 1,351 1,455 % Within Standard 5% 5% 4% 4% 8% 7% 7% 4% Source: PHS Data 8 to 9 9 to 1 1 to to to 13 Source: MUSE Database DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 13

20 DIVISION OF CARDIOLOGY Figure 44 Wait Times for Ambulatory ECG (Holter Monitoring) QEII Health Sciences Centre, # Weeks Figure 46 Wait Times for Ambulatory ECG (Loop Recording) QEII Health Sciences Centre, # Weeks Pacemaker/Device (AICD) Clinic A pacemaker clinic was initiated at Dartmouth General during 29/1. The combined total pacemaker visits from both sites is just slightly below 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 212/13 1,58 registrations for remote transmission monitoring were tracked. April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard In there were 1,48 loops done with a wait time of 2 weeks at the end of March 213. Figure 45 April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard Figure 47 Ambulatory Monitoring - Pacemaker Visits Capital Health, , 3,5 3, 2,5 Ambulatory Monitoring - Loop Volumes 1,8 # Visits 2, 1,5 1, # Loops 1,6 1,4 1,2 1, 8 1,21 1,364 1,518 1,527 1, to 9 9 to 1 1 to to to 13 DGH QEII 3,46 3,83 2,625 2,826 2,581 Total 3,46 3,432 3,387 3,35 3, Source: JEMS 8 to 9 9 to 1 1 to to to DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

21 Figure 48 Automatic Implantable Cardioverter Defibrillator (AICD) Clinic Visits & Remote Transmissions 4, # Visits 3,5 3, 2,5 2, 1,5 1, 5 8 to 9 9 to 1 1 to to to 13 Remote Transmissions ,81 1,48 1,518 Visits 2,57 1,94 2,44 1,797 1,934 Total 2,57 1,948 3,125 3,25 3,452 The wait for inpatient pacemaker insertion is 1 day and AICD insertion is 4 days. The wait is 25 days for outpatient pacemaker and 25 days for outpatient AICD implant. Figure 49 Wait Times for Inpatient Pacemaker Insertion QEII Health Sciences Centre, # Days Figure 51 Wait Times for Outpatient Pacemaker Insertion QEII Health Sciences Centre, # Days DIVISION OF CARDIOLOGY April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual/Surgery Data Pacemaker Standard April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual/Surgery Data Pacemaker Standard Figure 5 Figure 52 Wait Times for Inpatient AICD Insertion QEII Health Sciences Centre, Wait Times for Outpatient AICD Insertion QEII Health Sciences Centre, # Days # Days April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual/Surgery Data AICD Standard April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual/Surgery Data AICD Standard DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 15

22 DIVISION OF CARDIOLOGY Cardiac Catheterization Laboratory Procedures Cardiac Catheterization volumes have decreased slightly with 2,72 performed in 212/13 by Cardiologists. 1,812 percutaneous coronary interventions (PCI s) were performed which represents an increase compared to the previous year. In early April 29, it was identified that the APPROACH database report had been double counting the Both procedures as both PCI and CATH and should have only been counted as PCI thus inflating the Cardiac Catheter volumes prior to The numbers for years 24 to present have been changed to reflect the appropriate and consistent method of reporting this data which results in lower numbers overall. Figure 53 Figure 54 Percutaneous Coronary Intervention (PCI) Volumes 2,5 # PCI 2, 1,5 1, 5 Source: TomCat 1,673 1,798 1,99 1,744 1,812 8 to 9 9 to 1 1 to to to 13 Figure 56 Call Backs Capital Health, Source: CVIS Cardiac Catheterization Volumes QEII Health Sciences Centre , # Catheterizations 4, 3, 2, 1, Figure 55 Primary PCI Capital Health, March 213 shows the outpatient wait list with 256 patients waiting for a Catheterization or PCI procedure. Waits were higher in 211/12 due to the required de-commissioning of 2 cath labs to allow for new construction. Significant efforts were made to prevent waits from soaring by extending hours of the remaining labs to evenings and weekends. 8 to 9 9 to 1 1 to to to 13 Radiologists 1,733 1,792 1,74 1,671 1,388 Cardiologists 2,464 2,49 2,51 2,661 2,72 Total 4,197 4,282 4,241 4,332 4,18 Source: TomCat Source: CVIS 16 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

23 Figure 57 Outpatient Cardiac Catheterization & PCI Wait List QEII Health Sciences Centre, # Patients Figure 59 Cardiology Wait Times Semi-Urgent Cardiac Catheterization QEII Health Sciences Centre, # Days Figure 61 Cardiology Wait Times Urgent Percutaneous Coronary Intervention (PCI) QEII Health Sciences Centre, # Days DIVISION OF CARDIOLOGY April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual/CVIS April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual/CVIS Average Standard April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard Figure 58 Figure 6 Figure 62 Cardiology Wait Times Urgent Cardiac Catheterization QEII Health Sciences Centre, # Days Cardiology Wait Times Elective Cardiac Catheterization QEII Health Sciences Centre, # Days Cardiology Wait Times Semi-Urgent Percutaneous Coronary Intervention (PCI) QEII Health Sciences Centre, # Days April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual/CVIS Average Standard April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual/CVIS Average Standard April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 17

24 DIVISION OF CARDIOLOGY Figure 63 Cardiology Wait Times Elective Percutaneous Coronary Intervention (PCI) QEII Health Sciences Centre, # Days April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard Electrophysiology Laboratory Procedures Figure 64 Outpatient Wait Times for Urgent EP + Ablation QEII Health Sciences Centre, # Weeks April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard Figure 66 Electrophysiology Studies (EPS) + Ablation Performed 6 # EPS + Ablation Source: EPS Lab to 9 9 to 1 1 to to to 13 EPS/Ablation EPS 37 Figure 65 Outpatient Wait Times for Elective EP + Ablation QEII Health Sciences Centre, # Weeks April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard 18 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

25 Open-Heart Surgery Wait Times Figure 67 Cardiac Open Heart Surgery Wait Times In Hospital Urgent Category QEII Health Sciences Centre, # Days Figure 68 Cardiac Open Heart Surgery Wait Times Semi-Urgent Category QEII Health Sciences Centre, # Weeks Figure 69 Cardiac Open Heart Surgery Wait Times Scheduled Category QEII Health Sciences Centre, # Weeks DIVISION OF CARDIOLOGY April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Average Standard April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual Scheduled Standard DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 19

26 DIVISION OF CARDIOLOGY Patient Residency Distribution of patient residency is shown in figures This reflects our dual role as the Atlantic cardiac referral centre and the major secondary care centre for Capital Health. 44.7% of CCU, 23.5% of IMCU, 54.8% of ward patients and 82.4% of outpatients were from the Capital Health District. Figure 7 HI 6.4 Coronary Care Unit Inpatient Admissions Distribution of Patient Residency by Health District QEII Health Sciences Centre, Other: 11 NB, NF, PEI: 85 SSH: 46 PCHA: 32 GASHA: 23 SWH: 43 CDHA: 387 Figure 72 HI 6.2 IMCU Nursing Unit Inpatient Admissions Distribution of Patient Residency by Health District QEII Health Sciences Centre, GASHA: 34 CHA: 25 CEHHA: 75 PCHA: 35 SSH: 62 NB, NF, PEI: 75 Other: 13 SWH: 44 Figure 74 Cardiac Devices Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, NB, NF, PEI: 57 Other: 8 PCHA: 212 GASHA: 18 CHA: 134 SSH: 314 SWH: 217 CHA: 31 CBDHA: 81 CDHA: 795 CEHHA: 39 CDHA: 3,543 CEHHA: 62 AVDHA: 42 CBDHA: 333 AVDHA: 195 CBDHA: 98 AVDHA: 48 Figure 71 Figure 73 Figure 75 HI 6.1 IMCU Nursing Unit Inpatient Admissions Distribution of Patient Residency by Health District QEII Health Sciences Centre, Other: 21 NB, NF, PEI: 148 SSH: 95 PCHA: 81 SWH: 113 GASHA: 123 CHA: 69 CEHHA: 122 CDHA: 341 AVDHA: 112 CBDHA: 225 Cardiology General Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, Other: 12 NB, NF, PEI: 225 SWH: 11 SSH: 259 PCHA: 173 GASHA: 17 CHA: 73 CEHHA: 761 CBDHA: 111 AVDHA: 122 CDHA: 9,75 Cardiology Average Wait Time - Consult Request to Admit Ordered Capital Health, Average Wait Time - Consult Request to Admit Ordered (hrs) Benchmark Volume Volume *23-8 and 8-23 are based on consult request times. *Times included when the consulting service is also the admitting service Source: EDIS 2 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

27 Education Cardiologists provided 2 weeks as attending physician staff for MTU, 2 weeks as Senior Internist to the Emergency Department and 6 weeks 1 day on call to the Emergency Department. Undergraduate Medical Education The Metabolism II Block occurs in the midpoint of the second year of Medical School and involves Cardiology, Nephrology, and Respirology. The block underwent significant changes in its structure in the past couple of years but ran quite well again this year. Lectures were performed by the following Division members: Dr. N. Giacomantonio, Dr. B. Josephson, Dr. S. Ramer, Dr. R. Stewart, Dr. B. Clarke, Dr. M. Rajda, and Dr. C. Gray. Tutorials were supervised by the following physicians: Dr. C. Gray, Dr. T. Lee, Dr. M. Gardner, Dr. H. Beydoun, and Dr. N. Giacomantonio. Laboratory components were completed by the following: Dr. S. Jackson, Dr. H. Curran, Dr. N. Giacomantonio, Dr. C Koilpillai, Dr. R. Lodge, Dr. M. Love, Dr. T. Lee, and Dr. W. Sheridan. Clinical Skills teaching was performed by all members of the Division. Changes over the last one to two years in the Cardiology teaching service has led to most junior residents and clinical clerks doing in-patient services being focused on the 6.1 IMCU service. This, in addition to a focused teaching schedule, has led to a better experience for learners and feedback has been very good. Students can also spend time in the ambulatory clinic or on the ward. Future changes being seen in the clerkship may mean extra in-patient learners, particularly on the ward service. Postgraduate Medical Education This year has seen some changes in the Adult Cardiology Residency Training Program, perhaps most notably the change in Program Director from Dr. Jackson to Dr. Ramer. At the end of 212 we had 2 residents complete their training: Dr. Evan Merrick who is now practicing in Yarmouth, NS, and Dr. Doug Hayami currently enrolled in a combined Echo/Rehabilitation Fellowship at the Montreal Heart institute. Our new trainees who started in 212 are Dr. Matt Chamberlain and Dr. Jon Toma, both of whom came to us from Internal Medicine Training Programs in Ontario. Our resident complement is currently at 9 and will remain so for the upcoming academic year. Dr. Alex MacLean will be finishing up in September with an appointment at Dartmouth General Hospital thereafter. Dr. Mousa Al-Harbi will be staying on for a Fellowship in Electrophysiology, and Dr. Colin Yeung will be the Inaugural Fellow in Cardiac Rehabilitation. Joining our resident group in 213 will be Dr. Lindsay Carter from Dalhousie, Dr. David McFarlane and Dr. Bader Al-Shammari from the University of Toronto. We were very pleased with the quality of applications and applicants for our Cardiology spots this year; however, CaRMS funded spots continue to be somewhat short (2 spots this year.) We would like to have more CaRMS spots for next year as we have excellent internal applicants. 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 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 also 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 (currently Dr. Alex MacLean.) Wednesday mornings are core academic topics in Adult Cardiology (taken from the Royal College Objectives document), Thursday morning there is bedside teaching and/or research-in-progress rounds, and Friday morning there are rotating topics in cardiac hemodynamics, Interventional Cardiology and Cardiac Radiology. Friday at noon is regular ECG teaching and/or exam prep sessions. The training program has gone through changes in administrative support Ms. Cara Yee took over from Ms. Nicole Chiasson in July of 213, and in December of 213 Ms. Sandra Aucoin took over from Ms. Cara Yee. The administrative support has, despite these changes, run fairly smoothly throughout. 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. We had our 5 th Annual Combined Cardiology/Cardiac Surgery/Cardiac Basic Science Research Day this year on May 13 th. This was well attended and well received. Three of our residents were represented with posters/oral talks, and several of our 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. DIVISION OF CARDIOLOGY DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 21

28 DIVISION OF CARDIOLOGY Overall the divisional support of the Residency Training Program continues to be excellent which makes the job of the Residency Program Director somewhat easier. Thanks on behalf of the program to all of the Division members who make teaching a priority. Continuing Medical Education Cardiologists are active in the provision of continuing medical education, with presentations annually to general practitioners, specialists and other trainees. In 212/13 Cardiologists presented 56 lectures at local, national and international venues. Cardiologists also participated in 29 continuing medical education events to enhance their own education. Division members provided referee or editorial services to 45 journals/granting agencies in 212/13. There were 13 peer reviewed papers and 1 peer reviewed Letter to the Editor published by division members in 212/13. There were 13 abstracts and research presentations. Division members supervised 2 clinical clerks and 1 fellow in a directed research project. Dr. C. M. Kells, Certificate of Attendance June 1, 11, 12, nd Interventional Cardiology Symposium, Montreal at the Centaur Theatre. CME Credits: This event is an accredited group learning activity under Section 1 as defined by the Royal College of Physicians & Surgeons of Canada for the Maintenance of Certification Program. Approved by the Canadian Cardiovascular Society (CCS) for a total of 19.5 credits over the three days, 1 credit per hour (excluding Welcome Note, Q&A discussions and Flash from Industry.) Research 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. Dr. Jafna L. Cox Dr. Cox is the Director of Research in the Division of Cardiology, and the Inaugural Heart and Stroke Foundation Endowed Chair in Cardiovascular Outcomes. He continues to focus on the prevention of cardiovascular disease at the primary care level and specifically the ANCHOR study, performed in collaboration with the Nova Scotia Department of Health and Wellness and with the Capital District and Cape Breton Health Authorities. Much of his current research work involves the Canadian Network and Center for Trials Internationally (CANNeCTIN) in which he co-leads its knowledge translation silo; the GENESIS Study, an interdisciplinary enhancement team on gender and sex determinants of cardiovascular disease funded by CIHR and the Heart and Stroke Foundation of Canada; a CIHRfunded study seeking to measure and improve the quality of ST-segment elevation myocardial infarction (STEMI) care; and the Canadian CVCD (Cardiac, Vascular, Cognitive Dysfunction) Cohort Alliance that will survey cardiovascular disease over the course of a generation in conjunction with the Canadian Partnership for Tomorrow Project. His most recent research initiative, IMPACT-AF, with more than $5M in funding, involves yet another multilateral collaboration, with colleagues in electrophysiology and the Department of Computer Sciences, policy makers at the levels of the Nova Scotia Health Districts and Department of Health and Wellness, provider groups (including physicians, nurses, pharmacists), and patients and their advocacy groups, such as the Heart and Stroke Foundation, to develop computer decision support tools to optimize the outcomes and costs of patients with atrial fibrillation managed in primary care. Dr. Martin J. Gardner Dr. Gardner has continued involvement in the CASPER study and is the primary investigator of the family members group in this study. Results for the appearance of disease in asymptomatic family members was presented at the Canadian Cardiovascular Congress and the Heart Rhythm Society meeting. The manuscript has been submitted. He and his Canadian colleagues launched a new national registry for Arrhythmogenic Right Ventricular Cardiomyopathy. This Heart and Stroke funded registry will involve 1 centres in Canada and will enter 2,5 patients and family members over 5 years. This study will be the largest ARVC registry in the world and will generate data on early diagnosis, risk factors for sudden death and genetic findings across the country. Dr. Gardner is the chair of the steering committee for this study. Dr. Nick B. Giacomantonio Dr. Giacomantonio has been active in behavioral modification research and understanding the concepts of built environments with Dr. Chris Blanchard. These projects are both interprovincial and throughout the Maritimes. He presently holds grant funding for ongoing community research projects that will include understanding the role of pharmacy in cardiac rehabilitation, the role of cardiac rehabilitation in the management of atrial fibrillation, inflammatory arthritis, multi-risk management, as well as remote patient monitoring and virtualization of Hearts in Motion. He was an honorable mention for the presentation of cost 22 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

29 effective mortality data from Hearts in Motion at the EuroPrevent meetings held in Rome, Italy. Other clinical research interests include acute coronary syndromes and evaluation of exercise performance in high risk patients without using traditional exercise stress testing. He continues to collaborate with several basic scientists at Dalhousie, including Dr. Chris Blanchard, Dr. Scott Grandy, and Dr. Marilyn MacKay-Lyons and with the Divisions of Endocrinology and Neurology. The ultimate goal remains to be provincial programming of community based multi-risk polyvascular prevention with strong prospective outcomes that prove cost efficiency. Dr. Ratika Parkash Dr. Parkash is an outcomes and clinical trials researcher in atrial fibrillation and cardiac implantable electrical devices (CIEDs). She is the principle investigator and main author of SMAC AF, a CIHR funded, multi center clinical trial in Canada examining the use of aggressive BP lowering in patients undergoing catheter ablation for AF. Recruitment is ongoing for this study and is expected to be completed in 14 months. In CIED research, there have been several publications this last year in this area, with a successful grant to perform a multicenter, prospective registry in Canada of the St. Jude Medical Riata lead, currently under advisory. As part of this work, Dr. Parkash was previously the Chair of the CHRS Device committee and led the work on the Riata lead done in Canada. This work received significant attention at the Heart Rhythm Society Sessions in Boston, May 212, and Dr. Parkash was interviewed by the Medical Post and the Wall Street Journal on this topic. The retrospective survey on Riata was accepted for publication in Heart Rhythm in 213. Dr. John L. Sapp Ongoing research efforts have centred primarily on ventricular tachycardia investigation and management. Over the last academic year the data from our initial human feasibility study of intramyocardial needle ablation for treatment-refractory ventricular tachycardia has been presented at scientific sessions and a manuscript has been prepared and submitted for peer review. The culmination of several years of research on utilizing body surface potential mapping to derive an inverse solution and quantitative its accuracy has been published in Circulation Arrhythmia, and has led to ongoing research efforts to improve rapid mapping of ventricular tachycardia. We have developed a template matching algorithm in collaboration with Dr. Milan Horacek, and developed a method for rapid computerized identification of sites of activation during ventricular tachycardia and during ventricular pacing. A provisional patent has been granted for this work and further research support is being sought to validate this approach, including a prospective study at our centre. Dr. Lawrence M. Title Dr. Title is the Director of Interventional Research and continues to participate in investigator-driven and contract clinical trials research. Dr. Title has participated in over 1 multicentre projects in the last year, including trials in interventional cardiology research, and secondary prevention strategies to prevent recurrent cardiovascular events or atherosclerosis disease progression. A number of these trials have recently had landmark publication in journals such as New England Journal of Medicine (e.g. HDL raising strategies: AIM-HIGH, & Dal-Outcomes Studies; and PCI vs. CABG in Diabetes: FREEDOM trial). He continues to be involved in the use of intravascular ultrasound, (IVUS) in assessing coronary artery disease progression. He is a steering committee member of the CIHR-sponsored Canadian Atherosclerosis Imaging Network (CAIN-3) project and continues as the Halifax principal investigator in this multicenter trial which is continuing to follow patients with serial IVUS and carotid artery imaging. He will continue his interest with IVUS-based projects with the upcoming pharmaceutical sponsored (Amgen) GLAGOV trial. This is a randomized, multi-center, placebo-controlled, study to determine the effects of AMG 145 treatment (a novel cholesterol lowering therapy: PCSK9 antibody) on atherosclerotic disease burden as measured by IVUS. Drs. Iqbal R. Bata, Hussein K. Beydoun, Brian, Clarke, Helen Curran, Tony Lee, Miroslaw Rajda, Michael P. Love and Sarah Ramer They continue to participate in important national and international clinical trials and outcomes research. New Division members have started their research activities. Dr. Sarah Ramer published a paper and a case report in Canadian Journal of Cardiology. Dr. Brian Clarke has remained connected with international heart failure research groups and has joined the Research Management Committee as a member. Dr. Tony Lee contributes to the interventional studies and has a published article as senior author in the BMJ journal Heart. Dr. Helen Curran continues research she started in Calgary and has initiated a project using the STEMI database evaluating the impact of systems of care innovations (i.e. Lifenet) on timely access to primary PCI for STEMI. The Division generated $2,17,66 in research grants ($1,27,64) and industry contracts ($718,994) during 212/13. DIVISION OF CARDIOLOGY DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 23

30 DIVISION OF CARDIOLOGY Administration Cardiologists perform the following administrative activities: Contribution (Committee / Position) Role Physician Adult Cardiology Residency Training Program Program Director Dr. S. Ramer Adult Cardiology Residency Training Program Associate Program Director Dr. E.B. Josephson Adult Congenital Heart Disease Program Medical Director Dr. C.M. Kells Ambulatory Care Director Dr. I.R. Bata Atlantic Canada Cardiovascular Conference Co-chair Dr. S.D. Jackson Cardiac Catheterization Laboratory Director Dr. A. Quraishi Cardiac Catheterization Laboratory Management Committee Chair Dr. A. Quraishi Cardiac In-patient Management Committee Chair Dr. R.H. Crowell Cardiac Patient Care Management Committee Chair / Co-Chair Dr. C.M. Kells (Chair) Dr. C. Gray (Co-chair) Cardioelectrodiagnostic Director Dr. W.J. Sheridan Cardiology Advisory Committee Chair Dr. C. Gray Cardiology Bed Manager Bed Manager Dr. A. Quraishi Cardiology Consult Service Director Dr. R. Lodge Cardiovascular Surgery Weekly Conference Chair Dr. A. Quraishi Clinical Associate Program Director Dr. B.J. Kidwai Clinical Trials Research Meetings Chair Dr. M.P. Love Congenital Structural Heart Interventional Program Cardiology Lead Dr. S.N. Nadeem Connective Tissue Program Medical Co-director Dr. S.G. Horne Coronary Care Unit Director Dr. R.H. Crowell Device/Pacemaker Program Director Dr. C. Gray Division Head/Service Chief Head/Chief Dr. C.M. Kells Division of Cardiology Chief Electoral Officer Dr. R. Lodge Division of Cardiology Interim Research Director Dr. M.J. Gardner 24 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

31 Contribution (Committee / Position) Role Physician Division of Cardiology Grand Rounds Coordinator Dr. S. Ramer Echo Management Committee Chair Dr. C.J. Koilpillai Echocardiography Fellowship Program Director Dr. R.L. Stewart Electrophysiology Fellowship Program Director Dr. C. Gray Electrophysiology Laboratory & Services Director Dr. J.L. Sapp Heart Function Program Medical Director Dr. M. Rajda Heart Transplant Program Medical Director Dr. M. Rajda IMCU Medical Director Dr. R.H. Crowell Inherited Heart Disease Clinic Director Dr. M.J. Gardner Interventional Fellowship Program Director Dr. H.K. Beydoun Interventional Research Director Dr. L.M. Title Non-invasive Laboratories Director Dr. C.J. Koilpillai Patient Information Transfer Project Co-chair Dr. E.B. Josephson STEMI & Non-STEMI Implementation Committee Chair Dr. A. Quraishi Ward 6.2 Medical Director Dr. W.J. Sheridan Weekly PCI Peer Review Weekly Conference Chair Dr. A. Quraishi Clerkship Program, Internal Medicine Assistant Director Dr. B.J. Kidwai Department of Medicine Deputy Chief Dr. S.D. Jackson Medical Teaching Unit Director Dr. S.D. Jackson Quality & Professional Appraisal Committee Chair Dr. R. Stewart Survey Committee, Division of Respirology Chair Dr. C.M. Kells Heart Health Program Chair Dr. C.M. Kells ACS Guidelines Implementation Committee for CDHA Chair Dr. A. Quraishi Cardiac Rehabilitation Program Medical Director Dr. N.B. Giacomantonio Community Cardiovascular Hearts in Motion Medical Director Dr. N.B. Giacomantonio Pulmonary Hypertension Program Medical Director Dr. S.D. Jackson Postgraduate Medical Education Associate Dean Dr. M.J. Gardner (until July 1 st, 212) DIVISION OF CARDIOLOGY DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY 25

32 DIVISION OF CARDIOLOGY Contribution (Committee / Position) Role Physician The Inaugural Heart and Stroke Foundation of Nova Scotia Endowed Chair in Cardiovascular Outcomes Research Chair Dr. J.L. Cox Heart Health Team Co-chair Dr. C.M. Kells American College of Cardiology American Board of Governors (November 29 to present) Governor for Atlantic Canada Dr. J.L. Cox Atlantic Canada Cardiovascular Conference Committee Co-chair Dr. I.R. Bata Dr. S.D. Jackson Canadian Cardiovascular Society Committee for Guidelines for Training & Competency Chair Dr. C.M. Kells Canadian Cardiovascular Society CRT Guidelines Committee Co-chair Dr. R. Parkash Canadian Cardiovascular Society Scientific Program Committee Subcommittee (Student Research Award Presentation) Chair Dr. L.M. Title Canadian Heart Rhythm Society (CHRS) Device Advisory Committee Deputy Chair Dr. R. Parkash Community Based Hearts in Motion Program Director Dr. N.B. Giacomantonio 26 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CARDIOLOGY

33 Division of Clinical Dermatology & Cutaneous Science DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE 27

34 DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE Physician Resources 11 dermatologists (3.8 FTE) 2 full time 9 part time (all community-based) Our Patient Care Dermatology Ambulatory clinics take place at the Victoria General Hospital, the IWK Health Center and Northwood Manor. There are clinics in General Dermatology, Surgical Dermatology, and Pediatric Dermatology as well as subspecialty clinics (Mycosis Fungoides Clinic, Gynecology/ Dermatology Clinic, Interdisciplinary Non-melanoma Skin Cancer Clinic, Geriatric Dermatology clinic and Vascular Birthmark Clinic.) Inpatient Consultation Services are provided at the QEII Health Centre, the IWK Health Centre and the Dartmouth General Hospital, and are available 24 hours every day. Emergency room services are available 24 hours every day. The Dermatology Treatment Unit at the Victoria General Hospital is open from 7: 17: hrs. every weekday and treats high volumes of patients requiring phototherapy and specialized nursing care. A Phototherapy Unit runs at the Aberdeen Hospital in New Glasgow and is supervised via telemedicine weekly by a division member who is also available for advice by telephone every weekday. Our Teaching Our residency training program presently has one resident who will be sitting the Royal College Examination in May/ June, 212, and one PGY4, one PGY3 and one PGY1. The Training Program received Full Approval at the Royal College Survey in 212, with many comments about the excellent functioning of the program. Our team always has rotating house staff. They come from Internal Medicine, Family Practice, Pediatrics and Plastic Surgery. Evaluations of our service from them are excellent, always with comments and thanks for the superb teaching from all of the Division members. Clinical clerks rotate on our service for a month at a time. We take part in lectures and seminars in the MSK/Derm course in Med II at Dalhousie University. Divisional Highlights Dr. Peter Green who was named Professor of the Year by the 213 graduating class and was Master of ceremonies for Convocation Gala, chosen by class of 212. Drs. Laura Finlayson and Scott Murray received Meritorious Service Awards (25 years). Dr. Langley was elected incoming President of the Canadian Dermatology Association. Dr. Miller completed his association with the Division on June 3, 212. New Programs and Initiatives The division of dermatology again utilized online learning resources extensively during second year medical student MSK/DERM teaching. Students had access to additional resources during the course that included a screencast video on skin structure and function, an online digital photolibrary and a question blog that was moderated by the course chair. Formative evaluation with self-testing questions was also available and specific online resources were developed to supplement case-based learning and lectures. The Interdisciplinary Non-melanoma Skin Cancer clinic, initiated in 211 with the Division of Plastic Surgery is working well. Patients are very satisfied to receive an assessment by Dermatology and an excisional procedure by Plastic Surgery at the same site on the same day. Now in its 4 th year, the monthly Geriatric Dermatology Clinic at Northwood Manor continues to function well. Developed to reduce travel and hospital visits for nursing home residents with stable skin conditions, the patients and staff continue to provide positive feedback on the value of this service. The 5 th Dr. J. Barrie Ross Lecture in Dermatology was presented by Dr. Regine Mydlarski, Director of Immunodermatology and Transplant Dermatolgy from the University of Calgary entitled: Bullous skin diseases from bench to bedside/ This was presented at Department of Medicine Grand Rounds on November 27, DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE

35 Work for the Nova Scotia Department of Health and Wellness Dr. Green is the Chair of The Sun Safe Nova Scotia Coalition with coordination and administration by Cancer Care Nova Scotia and close liaison with the National Skin Cancer Prevention movement. Dr. Finlayson is past president and a member of the committee. Nova Scotia was the first province in Canada to pass a bill banning use of tanning salons by individuals under age 19, and most other provinces have now followed this lead and either have legislation in place or pending. Quality and Patient Safety Dr. Finlayson conducted a review of the statistics and functioning of the Vascular Birthmark Clinic at the IWK. This clinic assesses and treats children with complex vascular lesions and serves all of the Maritime Provinces. A report was given at the Atlantic Provinces Dermatology Association Annual Meeting on June 1, 212 and to the Department of Medicine on September 12, 212. Shadow Charts There are no shadow charts used in Dermatology Clinics. Similar to Capital Health inpatient records, paper documents (flow sheets, notes) are kept in the Dermatology Treatment Unit for the duration of the treatment encounter, or until an interim summary is dictated by the supervising Dermatologist allowing for scanning of records up to that point. Patients are often treated 3 to 5 times per week, and it is not possible at the present time to expect a scanned or dictated record of recent treatment and patient progress to be available on Horizon Patient Folder. Public Education As part of the Canadian Dermatology Association Sun Awareness Week in June 212, Division members participated in the following events: A Skin cancer screening event in which 54 people were examined by a Dermatologist and 1 probable skin cancers were identified as well as 11 pre-cancerous lesions. 4 media interviews Clinical Services The Division of Clinical Dermatology and Cutaneous Science provides specialized ambulatory Dermatology care for patients in the Capital Health District, tertiary care for the province, and quaternary care to PEI. This includes: General Dermatology Outpatient Clinics at the QEII HSC Telemedicine Consultation Clinics to sites throughout Nova Scotia, New Brunswick, and PEI Dermatology Skin Treatment & Phototherapy Unit at the QEII HSC Outpatient Surgery Clinics Patch Testing Cutaneous T-Cell Lymphoma Clinic (Mycosis Fungoides) Telemedicine Phototherapy Unit at Aberdeen Hospital in New Glasgow, NS General Paediatric and Paediatric Birthmark/Vascular Lesion Clinics at the IWK Health Centre Multi-disciplinary Gynaecology-Dermatology Clinic DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE Dr. Finlayson joined the Department of Medicine Quality and Professional Assessment Committee and established a Divisional Quality Committee in 212/13. Distribution of Information packages to 3 elementary schools Provision of print information materials and sunscreen samples to the general public. Interdisciplinary Non-Melanoma Skin Cancer Clinic (INSCC) Geriatric Dermatology Clinic at Northwood Manor, Halifax, NS DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE 29

36 DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE Emergency Coverage Dermatologists provide 24 hour, 7-day emergency and on-call coverage for patients throughout the province. The call schedule is circulated to the IWK HC Emergency and QEII HSC locating departments. All division members (including community-based physicians) are incorporated into the call schedule, and act as a tertiary care provincial resource, responding to referrals and consultations on a 24-hour basis, 7 days per week. Inpatient Services There are no designated Dermatology beds at the QEII HSC and, therefore, no dermatology inpatient services in the Province of Nova Scotia. Emergency patients are admitted through the ED under Internal Medicine and the Dermatologist acts as a consultant. Consultation and emergency coverage are provided by staff physicians on a rotational basis. Inpatient Consultations There were 114 inpatient consults by Dermatologists reported by Physician Services in 212/13. Additionally, there were 61 QEII HSC inpatients seen in the Dickson outpatient clinic in 212/13. The Division of Clinical Dermatology and Cutaneous Science provide inpatient consultation service to the IWK HSC and other services at the Halifax Infirmary, VG, and NSRC sites of the QEII HSC. Consultative coverage is provided to the Dartmouth General Hospital via a community based dermatologist. A consultation service is also provided outside Capital Health to other areas of the province. Inpatient consultations are provided, via telemedicine, to remote hospitals in Nova Scotia, New Brunswick, and PEI. Ambulatory Care The Division of Clinical Dermatology and Cutaneous Science has a very active Ambulatory Care Service. In addition to daily clinics in General Dermatology at the QEII, there are Surgical Dermatology Clinics, Gynecology- Dermatology Clinics, Patch test Clinics, Cutaneous Lymphoma Clinics and the Interdisciplinary Non-Melanoma Skin Cancer Clinic. In addition, we provide monthly Geriatric Dermatology Clinics at Northwood Manor and three weekly General Pediatric Dermatology Clinics and a Vascular Birthmark Clinic at the IWK Health Centre. The Outpatient Phototherapy and Treatment Unit sees approximately 9, patient visits per year and is instrumental in providing daily care for patients with severe skin disease who previously would have required hospitalization. Division members also supervise the Phototherapy Unit at the Aberdeen Hospital via telemedicine and conduct Telemedicine Consultation Clinics, with the ability to provide consultations to 46 sites in the Maritime Provinces. Round the clock continuous service is provided for consultations in all of the Capital Health Emergency Departments and for hospitalized inpatients in all of the affiliated institutions. Division members also respond to a wide variety of calls for advice from all regions of the Atlantic Provinces. There were 15,93 patient visits to the 4 th floor Dickson Dermatology clinics in 212/13; registrations include patients attending for dermatology consults (including telemedicine consult service), day surgery and phototherapy/treatment. The total practitioner encounters in the 4 th floor Dickson Dermatology clinics are higher than registered visits given patients may see multiple providers during a clinic appointment (i.e., physicians, phototherapist, and/or nursing). However, only one registration is completed due to the functionality of the STAR registration system and limited clerical resources. Therefore, if multiple providers see a patient during a visit each provider s involvement is not necessarily captured via the registration process. In 3 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE

37 the past, data from STAR and the GRASP nursing database were collated to account for the difference. Based on GRASP data between 24 and 27, approximately 6% of patients see nursing during their treatment visit with the phototherapist. Dermatology Outpatient Clinic There were 6,249 visits registered to the Dermatology Outpatient Clinic in 212/13, representing a 1.3% increase from the previous year. Due to registration process issues in the Dermatology Day Surgery Service, visits to the Dermatology Outpatient Clinic are overreported for the period of January 212 to March 213. There were an additional 118 chart checks performed in 212/13 not included in the following figures. Figure 1 Dermatology Outpatient Clinic Ambulatory Care Registrations 8 Registrations Figure 2 Dermatology Outpatient Clinic New and Return Ambulatory Care Registrations 7, Registrations 6, 5, 4, 3, 2, 1, New Return 2,523 2,959 3,18 3,647 4,7 Total 4,329 4,656 4,862 5,667 6,249 % New 41.6% 36.4% 35.9% 35.5% 34.5% Dermatology Day Surgery There were 345 visits registered to the Dermatology Day Surgery Clinic in 212/13. Due to registration process issues, visits to the Dermatology Day Surgery/Minor Procedures Service are under-reported between January 212 and March 213. Figure 3 Dermatology Day Surgery Ambulatory Care Registrations 14 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Figure 4 Dermatology Surgery New and Return Ambulatory Care Registrations 1, Registrations DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE 2 1 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total , , , , ,249 Of the visits registered to the Day Surgery Clinic in the 212/13, 41.2% of patients were initially seen in the outpatient clinic and subsequently scheduled for same-day surgery thus reducing frequency of hospital visits. Due to limitations with the STAR system, the registration can only capture a single physician encounter per day New Return Total % New 21.6% 23.9% 22.5% 27.2% 23.5% DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE 31

38 DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE Dermatology Phototherapy and Skin Treatment Unit The Dermatology Phototherapy and Skin Treatment Unit is the only service of its kind in the Maritime Provinces. The unit provides treatment to patients with severe skin disease. The patient is assessed by a Dermatologist before beginning a treatment series. Treatments are adjusted by the physician, as necessary, throughout the treatment series. In 212/13, there were 1,218 treatment encounters registered to physicians, which is a.7% increase from 211/12. Dr.Tremaine followed 41.% of the treatment patients, Dr. Finlayson followed 41.2% and Dr. Green followed 17.8%. This figure includes physician encounters with patients receiving phototherapy treatment in New Glasgow via telemedicine. Table 1 Dermatology Treatment, Non-Series, Physician Ambulatory Care Registrations QEII HSC (including Telehealth), QUARTER Finlayson Green Tremaine TOTAL TOTAL ,156 % TOTAL 4.9% 18.2% 4.9% 1.% TOTAL ,29 % TOTAL 42.5% 17.9% 39.5% 1.% In 212/13, there were 9,139 non-physician visits registered to the Phototherapy and Skin Treatment Unit, which is a 7.8% increase from the previous year. As previously mentioned, approximately 6% of treatment visits see nursing prior to the phototherapist. With the discontinuation of the GRASP workload measurement tool, data on individual practitioner encounters was not available for 211/12. Figure 5 Dermatology Treatment, Series, Phototherapist Ambulatory Care Registrations 1, Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total , , , , ,139 Registrations TOTAL ,218 % TOTAL 41.2% 17.8% 41.% 1.% 32 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE

39 Telemedicine Clinics The Dermatology division provides telemedicine consultation clinics and phototherapy clinics to remote hospitals in Nova Scotia, New Brunswick, and PEI. As part of the Telemedicine Service, Dr. Finlayson and Dr Murray provide a Teledermatology Consultation clinic from the Dickson Dermatology clinic at the QEII. In addition, Dr. Finlayson supervises the Teledermatology Light Therapy Clinic at the Aberdeen Hospital in New Glasgow, NS. This is a fully integrated program and is affiliated with the Dermatology Skin Treatment and Phototherapy Unit at the QEII HSC. Telemedicine Consultation Service There were 84 visits registered to the Telemedicine Consultation Service in 212/13, which is inline with 211/12. Historically, the majority of patients who access this service reside in the Guysborough Antigonish Straight or Pictou County Health Authority. A community Dermatologist left private practice in Antigonish in early 211/12, and demand for telemedicine services from Halifax has steadily increased since. Limited infrastructure and clerical resources at other remote sites continues to hinder coordination of visits; additional funding and IT efficiencies continue to be explored with the Nova Scotia Department of Health and Wellness. To accommodate for these challenges, non-urgent consults from these areas are triaged and Halifax clinic appointments are provided where required. Additionally, where required, patients are seen in clinic for follow-up. Figure 6 Dermatology Telemedicine Consultation Ambulatory Care Registrations 25 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Figure 7 Phototherapy and Light Therapy Clinic: Aberdeen Hospital, New Glasgow, NS Dermatology Telemedicine Consultation New and Return Ambulatory Care Registrations 15 Registrations New Return Total % New 85.1% 38.2% 66.% 63.4% 76.2% In 212/13 a total of 2,357 treatment visits occurred to Aberdeen Hospital Phototherapy Unit, which is a 22.4% increase from the previous year. Actual encounters with Halifax-based Dermatologists are included in Table 1. Table Visits New Patients Discharges Source: Aberdeen Hospital - Physiotherapy Department DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE 33

40 DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE Special Service Commitments The Division provides special service commitments at the QEII HSC, IWK HC and community. Both hospital-based and community dermatologists see paediatric patients at the IWK HC; teaching clinics also occur at the IWK HC each week. Teaching is provided to medical students, dermatology residents, paediatric residents, plastic surgery residents, and family practice residents. Cases can vary from common diaper rashes to extremely rare childhood diseases. A total of 1,257 paediatric patient visits occurred in 212/13 at the IWK HC. This represents a 7.3% increase from the previous fiscal year. Figure 8 Dermatology Pregnancy & Diabetes Registrations IWK Hospital, April 29 - March 213 1,5 1,25 Dr. Miller resigned June 3th 212. He participated in a Leg Ulcer Clinic as part of the Vascular Surgery Clinic at the HI site. Data for the 1st quarter of 212/13 is shown below. Figure 9 Dermatology Leg Ulcer Clinic Ambulatory Care Registrations 4 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total The Multidisciplinary Gynaecology-Dermatology Clinic began in October 28. Dr. Baxter attends this biweekly service along with members of the Department of Gynaecology. Patients are booked and registered to the most appropriate subspecialist for their condition, and cross-consultation occurs if required. There were 175 visits registered to Dr. Baxter in 212/13, of which 35.4% were new consults. Figure 1 Gynecology-Dermatology Clinic Ambulatory Care Registrations QEII Health Sciences Centre, April 29 - March Registrations Registrations 1, Return New Total %New 36.7% 32.9% 36.6% 37.% Finlayson Green Murray Total 1,116 1,17 1,171 1,257 Source: Meditech Dr. Finlayson started a monthly Geriatric Dermatology Clinic at Northwood Manor in Halifax in March 29. Consults are performed in onsite clinic space, and supported by a nurse practitioner. There were 31 visits registered during 212/13, with 77.4% being new consults. Dr. Purdy started the bi-weekly Interdisciplinary Non- Melanoma Skin Cancer Clinic in September 211 along with Plastic Surgery. Patients are typically seen by both specialties in the same visit, and an excisional minor procedure can often be performed that same day. There were 57 visits in 212/ DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE

41 Medical Day Unit There were 67 patients registered under the Dermatology Services who were seen in the Medical Day Unit in 212/13. This is indicated in the graph below. The annual numbers have decreased in recent years as newer treatments are implemented. Figure 11 Dermatology Medical Day Unit Ambulatory Care Registrations 14 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Ambulatory Care Wait Times Guidelines for the triage of new referrals to Dermatology Outpatient clinics are identified below. Urgent, Semi-Urgent and Non-Urgent consults are typically faxed or mailed, and are triaged by the full-time hospital-based division members. Most emergent cases are referred by direct physician-to-physician communication, and therefore not triaged. The wait times by quarter have been published on the Department of Medicine website. Table 3 Triage Category Emergent Priority 1 Potentially life threatening conditions. Examples include: Severe drug eruptions Bullous diseases Erythrodermas Severe skin infections Urgent Priority 2 Significant potential for early intervention to save life/prevent hospitalization or functional impairment. Examples include: Melanomas Severe dermatitis or Papulosquamous diseases Progressing undiagnosed skin conditions Semi-urgent Priority 3 Stable but significant skin conditions or stable undiagnosed skin conditions. Examples include: Chronic psoriasis Chronic eczemas Alopecia Non-urgent Priority 4 Stable patients with known skin conditions where rapid deterioration is unlikely. Reassessment of stable patients for review of current treatment. Examples include: Mile chronic psoriasis or eczema Warts Simple Acne Nail Disorders Standard Wait Time Within 1 day Within 1 week Within 8 weeks Within 4 months DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE 35

42 DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE Average wait times by triage categories for the 212/13 year are shown below. Limited infrastructure at remote sites has historically hampered the level of service in the Telemedicine Clinics; and can result in delays in many cases. Figure 12 Dermatology New Emergent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 1% 1% 83% 1% 1% 97% 1% 1% Source: PHS Data Figure 13 Dermatology New Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 93% 95% 88% 97% 97% 88% 89% 1% Source: PHS Data Figure 14 Dermatology New Semi-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Figure 15 Dermatology New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait 6 Maximum Wait % Within Standard 54% 69% 75% 59% 78% 65% 57% 48% Source: PHS Data Figure Dermatology Telemedicine New Non-urgent Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Days Average Wait Time Standard Wait Time Count Minimum Wait 1 Maximum Wait % Within Standard 83% 83% 72% 75% 77% 81% 7% 67% Source: PHS Data Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 77% 33% 67% 6% 46% 33% 78% 1% Source: PHS Data 36 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE

43 Clinic No Shows Patients are considered a no show if they have not called to cancel or reschedule their clinic appointment before the appointment date. There were 542 no shows to 4 th floor Dickson Dermatology Clinics over 212/13, resulting in a 6.9% no-show rate. A significant volume of no shows occur with treatment or phototherapy visits. Dermatology recently implemented an automated call reminder system and reductions in no-show rates, particularly for those appointments booked well in advance, are anticipated. After roughly one year, rates for individual practitioners and triage categories are relatively stable. The overall no-show rate to telemedicine, including physician consult for Phototherapy being administered in New Glasgow was.7%. Table 4 No Show by Practitioner Dermatology, QEII Health Sciences Centre Provider Booked No Show % No Show Baxter, Mary Louise S % Finlayson, Laura A % Gallant, Christopher J % Green, Peter J % Langley, Richard G % Murray, Scott J % Purdy, Kerri % Torok, M Theresa % Tremaine, Robert D % Total 7, % Table 5 No Show by Procedure Dermatology, QEII Health Sciences Centre Procedure Booked No Show % No Show New Emergent Consult Dermatology (<24 hours) % New Urgent Consult Dermatology (1-7 days) % New Semi-Urgent Consult Dermatology (1-8 weeks) % New Non-Urgent Consult Dermatology (2-4 months) 1, % New Semi-Urgent Consult Dermatology Plastics (7-56 days) 9 -.% New Non-Urgent Consult Dermatology Plastics (56-12 days) 2 -.% New Consult Dermatology Treatment Physician % New Gynecology/Dermatology % Return Visit 3, % Return Dermatology Treatment % Return Dermatology Patch Clinic % Return Dermatology Plastics % Return Derm/Plastics Non-Melanoma Skin CA MP (Biopsy/Simple Excise) 3 -.% Return Gynecology/Dermatology % Return Mycosis Fungoides 24 -.% Return Patch Test Reading 97 -.% Return Suture Removal % Minor Procedure (Day Surgery) % Reports Gynecology/Dermatology 8 -.% Total 7, % Table 6 No Show by Procedure Telemedicine, QEII Health Sciences Centre Procedure Booked No Show % No Show Telehealth Dermatology New Urgent (Within 7 days) 2.% Telehealth Dermatology New 63.% Telehealth Dermatology Phototherapy % Telehealth Dermatology Reassess 1.% Telehealth Dermatology Return % Total % DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE 37

44 DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE Patient Demographics The following graphs represent the distribution of patient residency by Health District. 33.3% of visits to the outpatient clinic, and 25.5% of visits to the day surgery clinic were from outside the Capital Health. Information on Telemedicine sites is also provided here. The number of telemedicine consults coming in from the southern portion of Nova Scotia continues to be few. This is in part due to lack of knowledge on the part of physicians that the service exists but also on the lack of infrastructure in that area. The Department of Health and Wellness is aware of this issue. Figure 17 Dermatology Outpatient Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, PCHA: 314 NB, NF, PEI: 168 SWH: 13 SSH: 362 Figure 18 Dermatology Day Surgery Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, PCHA: 15 GASHA: 1 CHA: 1 CEHHA: 27 Figure 19 Other: 1 NB, NF, PEI: 4 SWH: 3 SSH: 12 CBDHA: 2 AVDHA: 13 Dermatology Telemedicine Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, AVDHA: 1 SSH: 3 SWH: 1 CDHA: 257 The following graphs represent the distribution of patients by age and gender. Figure 2 Dermatology Outpatient Clinic Registrations Percent Distribution by Age and Gender QEII Health Sciences Centre, Age Group % % 17.9% 11.5% 12.8% 12.9% 12.1% 6.6% 8.4% 2.1% 7.2% 1.2% 8.8% 8.7% 1.3% 14.8% 2.1% 17.7% 5.% 4.% 3.% 2.% 1.%.% 1.% 2.% 3.% 4.% 5.% Female Male Figure 21 GASHA: 18 CHA: 72 CEHHA: 632 CBDHA: 9 AVDHA: 234 CDHA: 4,166 PCHA: 27 CBDHA: 2 Dermatology Day Surgery Clinic Registrations Percent Distribution by Age and Gender QEII Health Sciences Centre, Age Group % % 6.8% 3.% 15.1% 2.5% CEHHA: % 13.6% 17.5% 21.1% % 9.6% % 6.% GASHA: % 4.8% % 2.4% 5.% 4.% 3.% 2.% 1.%.% 1.% 2.% 3.% 4.% 5.% Female Male 38 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE

45 Figure 22 Dermatology Telemedicine Clinic Registrations Percent Distribution by Age and Gender QEII Health Sciences Centre, Age Group % % 18.5% 13.% 14.8% 11.1% 11.1% 3.7% 1.9%.% 3.3% 6.7% 1.% 1.% 1.% 16.7% 16.7% 26.7% 5.% 4.% 3.% 2.% 1.%.% 1.% 2.% 3.% 4.% 5.% Female Male Figure 23 Dermatology Treatment Registrations Percent Distribution by Age and Gender QEII Health Sciences Centre, Age Group % 24.6% 15.3% 12.3% 9.3% 1.2%.1%.% 2.6% 4.9% 7.5% 8.2% 12.2% 16.% 23.7% 22.1% Education Our Program for elective positions for Med III Clinical Clerks, Family Medicine Residents, Internal Medicine Residents, Pathology Residents and Plastic Surgery Residents is always fully subscribed, with a waiting list. Pediatric Residents frequently attend the Pediatric Dermatology clinics held at the IWK In addition to providing CME to Family Physicians and other Dermatologists and Cutaneous Scientists, our Division provided educational presentations to Nurses, Pharmacists, the Sun Safe Nova Scotia Coalition, the Scleroderma Society of Canada and the Lupus Society of Canada. Undergraduate Medical Education Division members take part in lectures and seminars in the MSK/Derm course in Med II. 1.5 Med II electives rotated in Dermatology in 212/13. 1 clinical clerks, including 1 Med IV elective, did 4-week rotations through the division in the 212/13 academic year. Division members delivered 58 hours of Med I Clinical Skills teaching, 8 hours as preceptors for Med I Rotating Electives, 8 hours of teaching in Med III Clerkship Seminars and 4 hours as Med II OSCE examiner in 212/13. Dermatology did not provide service to the MTU or Senior Internist rotations due to the shortage of full-time dermatologists. As outlined in the 27 divisional survey, the division is working to procure funding for an additional full-time dermatologist. Sub-specialty Medical Education The Dalhousie Dermatology Residency Training Program was granted full accreditation by the Royal College of Physicians and Surgeons Survey process in February 212 with many comments about the excellent functioning of the program. Dr. O Blenes completed Dermatology residency training on June 3, 213 and plans to join the Dalhousie Division of Clinical Dermatology and Cutaneous Science as a part time member August, 213. The Program currently has a PGY5, PGY4 and PGY2 resident enrolled in the 213/14 academic year. Continuing Medical Education Dermatologists are active in the provision of continuing medical education (CME). Division members delivered 31 Continuing Medical Education presentations in 212/13. DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE % 5.3% 5.% 4.% 3.% 2.% 1.%.% 1.% 2.% 3.% 4.% 5.% Female Male Postgraduate Medical Education 9 residents from various disciplines rotated through the Dermatology service for 4 weeks each during the 212/13 academic year Division members delivered 3 hours of Academic Half-Day Teaching, and 5 hours as examiners for Resident OSCE in 212/13. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE 39

46 DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE Research There were approximately 16 publications and 8 presentations at local, National/International meetings within the Division during 212/13. The Division generated $489. in research grants during 212/13. Administration The division members were involved in the following administrative activities: Division Head/Service Chief, including all responsibilities of the position. Division members act as Directors/Head/Chairs for: Director of Outpatient Clinics and Treatment Unit Director of Paediatric Dermatology Director of Dermatologic Surgery Program Director, Dermatology Residency Training Program Director of Research Director, Undergraduate Medical Education, Dermatology Director, Teledermatology Chief, Dermatology Services DGH Chief of Service (Dermatology) IWK Chair, Dermatology Morbidity and Mortality Committee Chair, DOM Financial Management Committee Chair, DOM Investment Portfolio Sub-Committee Chair, Sun Safe Nova Scotia Coalition, Cancer Care Chair, Curriculum Committee for Dermatology Chair CDA Annual Meeting Scientific Committee Division members provided referee or editorial services to 7 journals/granting agencies in 212/13. 4 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF CLINICAL DERMATOLOGY & CUTANEOUS SCIENCE

47 Division of Digestive Care & Endoscopy DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF DIGESTIVE CARE & ENDOSCOPY 41

48 DIVISION OF DIGESTIVE CARE & ENDOSCOPY Physician Resources The total physician complement in the Division for the 212/13 year was 1.95 FTE gastroenterologists. Therapeutic Endoscopy The Division provides advanced therapeutic endoscopy interventions for Capital District and for the province. The Cobequid Endoscopy Service continues to be a major centre for assessment and endoscopy of patients referred from primary care. There were 1,784 patient registrations to Cobequid in 212/13. Provincial Colon Cancer Screening Program Division members have been integral to the establishment of the program, ensuring a high quality service for the important screening modality. Motility The Gastroenterology Division is the only unit operating esophageal and colonic motility studies in Nova Scotia. 155 procedures were done this year on patients with motility disorders. This helps provide guidance to internists, surgeons and others with regard to management of patients with refractory reflux disease or anal rectal motility disorders. Nutrition The division has also taken responsibility for the insertion of percutaneous gastroscopy tubes in patients with ENT and other cancers, who are unable to eat. 3 percutaneous gastroscopy procedures were performed during 212/13. Emergency Coverage Gastroenterologists provide 24 hour, 7-day/week emergency and on-call coverage for patients in the Capital District Health Authority. IBD The service provides support to physicians around the province who are managing patients with these difficult diseases. 42 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF DIGESTIVE CARE & ENDOSCOPY

49 Inpatient Services There have been significant changes to the number of inpatient beds managed by Gastroenterologists. Beds have been reduced from 12 beds in to 9 beds in In August of 21 beds were reduced to 6. Beds are now reduced to 2 and are located on 6B VG site. Most patients are admitted to the Medical Teaching Units at the HI site. Figure 1 Gastroenterology Inpatient Admissions 5 Figure 3 Gastroenterology Inpatient Bed Occupancy Rate by Fiscal Year 18% Percent Occupancy 16% 14% 12% 1% 8% 6% 4% 69.3% 6.6% 1.% 12.3% 163.% Inpatient Consultations There were 942 inpatient consults reported by gastroenterologists in 212/13. Division gastroenterologists provided inpatient and emergency room consultations to the HI and VG sites, the IWK Health Centre and the Dartmouth General Hospital. DIVISION OF DIGESTIVE CARE & ENDOSCOPY % Admissions % Figure 4 5 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Gastroenterology Bed Day Utilization by Fiscal Year 4, 3, Figure 2 Bed Days 2, Gastroenterology Inpatient Average Length of Stay (Days) by Fiscal Year 14 1, Used 2,189 2,37 2,542 1,397 1,133 Avail 3,157 3,364 2,541 1, Days DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF DIGESTIVE CARE & ENDOSCOPY 43

50 DIVISION OF DIGESTIVE CARE & ENDOSCOPY Ambulatory Care Clinics The VG site Gastroenterology staff registered 9,27 clinic visits and 4,65 endoscopy procedure visits. An additional 539 visits for endoscopy procedures performed by GI physicians were registered at the HI site and 1,784 visits at the Cobequid endoscopy clinic. GI ambulatory care clinics include GI General, GI Liver Transplant, and Endoscopy Procedures. Dr. Turnbull sees patients monthly at the Neurogenic Bowel clinic at the Nova Scotia Rehabilitation Centre. Clinics There were 8,467 visits registered in 212/13. These registrations include Home Pen Program patients, GI Surgery patients and GI Division physician s new patients who have been triaged as C1, C2 and C3 and return visits. There were an additional 2,92 chart checks performed in 212/13 not reported in the following figures. 11 Neurogenic Bowel registrations are included in the graph below for 212/13. Figure 6 GI General New and Return Ambulatory Care Registrations 8, Registrations 7, 6, 5, 4, 3, 2, 1, New 1,876 2,18 2,198 2,538 2,693 Return 2,75 3,8 3,576 3,978 4,371 Total 4,626 5,116 5,774 6,516 7,64 % New 4.6% 41.2% 38.1% 39.% 38.1% Endoscopy Figure 8 GI Endoscopy VG Site, GI Physicians Ambulatory Care Registrations 1, Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total , , , , ,65 The 9 th Floor Endoscopy Unit registered 4,65 visits for GI Medicine practitioners. Figure 5 Figure 7 Figure 9 GI Clinics Ambulatory Care Registrations 9, 8, GI Liver Transplant Ambulatory Care Registrations 8 7 GI Endoscopy HI Site, GI Physicians Ambulatory Care Registrations 12 1 Registrations 7, 6, 5, 4, 3, 2, 1, NS Home Pen Program GI Surgery 1,77 1,838 1,639 1,523 1,375 Gastroenterology 4,591 5,68 5,728 6,478 7,64 Total 6,433 7,14 7,431 8,46 8,467 Registrations GI Preliver Transplant GI Liver Transplant Total Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF DIGESTIVE CARE & ENDOSCOPY

51 Figure 1 GI Endoscopy Cobequid Site, GI Physicians Ambulatory Care Registrations Cobequid Community Health Centre, June 28 - March Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total , , , ,784 Ambulatory Care Wait Time New Consults are triaged as C1 (emergent within 7 days), C2 (urgent within 49 days) and C3 (non-urgent within 21 days). The majority of referrals accepted are triaged as urgent or semi urgent. Most non-urgent referrals are returned to the referring physician with advice on how to manage the patient s GI disease. Referrals are also returned if more information is required to appropriately triage the referral. 143 referrals were returned to primary care physicians between April 211 and March 31, 212. Figure 11 Gastroenterology New Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Figure 12 Gastroenterology New Semi-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 33% 42% 27% 31% 27% 25% 29% 24% Source: PHS Data DIVISION OF DIGESTIVE CARE & ENDOSCOPY Days 1 5 Figure 13 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 36% 32% 31% 5% 31% 41% 38% 55% Source: PHS Data Gastroenterology New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 91% 78% 64% 52% 43% 48% 37% 48% Source: PHS Data DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF DIGESTIVE CARE & ENDOSCOPY 45

52 DIVISION OF DIGESTIVE CARE & ENDOSCOPY Figure 14 Gastroenterology Liver Clinic New Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 78% 5% 33% 4% 8% 4% % 63% Source: PHS Data Figure 16 Gastroenterology Liver Clinic New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 71% 57% 66% 47% 69% 76% 62% 6% Source: PHS Data Clinic No Show The overall No Show rate for endoscopy procedures was 2.2% for the year. The overall No Show rate for clinic visits by Gastroenterologists including liver was 7.3% for the year. Patients receive reminder calls of their appointment. Medical Day Unit There were 2,21 GI patient visits registered in the Medical Day Unit in 212/13. Figure 15 Gastroenterology Liver Clinic New Semi-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days 5 25 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 23% 14% 2% 19% 33% 19% 24% 38% Source: PHS Data 46 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF DIGESTIVE CARE & ENDOSCOPY

53 Distribution of Patients by Age Figure 17 GI General Clinic Registrations Percent Distribution by Age and Gender QEII Health Sciences Centre, Age Group % 16.9% 2.% 14.1% 9.9% 11.8%.6%.1% 3.4% 4.8% 11.7% 12.5% 1.% 15.7% 2.1% 23.1% Distribution of Patients by District Figure 18 Gastroenterology General Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, Other: 31 NB, NF, PEI: 77 SWH: 53 SSH: 11 PCHA: 93 GASHA: 44 CHA: 46 CEHHA: 35 CDHA: 6,5 Education Gastroenterologists provided 6 weeks as attending physician staff for MTU and 35 night/weekend shifts to the Emergency Department. Undergraduate Medical Education: Gastroenterologists contribute directly to undergraduate education by tutoring, lecturing, clinical demonstrations, evaluation, electives and course development throughout the academic year. 28 undergraduate medical students rotated through Gastroenterology for a one, two or three week rotations in 212/13. DIVISION OF DIGESTIVE CARE & ENDOSCOPY % 5.% 4.% 3.% 2.% 1.%.% 1.% 2.% 3.% 4.% 5.% Female Male 1.9% CBDHA: 64 Figure 19 AVDHA: 146 Division members contributed 116 hours of Med 1 Clinical Skills training, 8 hours of Med 1 rotating electives, 44 hours of Med 1 & 2 Case Base Learning tutoring, 12 hours of lectures for the Consolidation Unit, and 14 hours of lectures to the Med 3 Wednesday Seminars. They also participated for 8 hours as Med 2 OSCE examiners and hours as Med 3 OSCE examiners. Gastroenterology General Clinic Registrations Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, Postgraduate Medical Education: 33 residents did 4-week rotations in the Gastroenterology Service during the 212/13 academic year, including 28 Core Internal Medicine residents and 5 external residents, from General Surgery, Radiation Oncology and Radiology. Out of Province: 18 Division members provided: Non Capital District: 96 Capital District: 6,5 1 hours as examiners for resident OSCEs 12 hours of Core Internal Medicine Academic Half Day presentations 8 hours of CaRMS file review and 8 hours as CaRMS interviewers DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF DIGESTIVE CARE & ENDOSCOPY 47

54 DIVISION OF DIGESTIVE CARE & ENDOSCOPY Research The Division generated $469,561 in research grants and industry contracts during 212/ DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF DIGESTIVE CARE & ENDOSCOPY

55 Division of Endocrinology & Metabolism DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM 49

56 DIVISION OF ENDOCRINOLOGY & METABOLISM Physician Resources 5.12 FTE (3.5 Clinical) 5 full-time, 1 part-time, institution based endocrinologists Divisional Highlights Division members continue to undertake all aspects of our mandate including clinical activities, on-call consultation service, clinical research, clinical trials, basic research and teaching at all levels, including outreach to general practitioners. Dr. Yip joined the Division on a full-time basis in the fall of 212, who like other recent recruit Dr. Tugwell, will focus mainly on Diabetes. New Programs and Initiatives Dr. Imran, in association with Dr. Rajaraman of Radiation Oncology has developed interprovincial thyroid oncology rounds where physicians from the Atlantic Provinces discuss difficult thyroid cancer patients. These rounds occur on a monthly basis and are attended by Surgeons, Endocrinologists, Nurses and other physicians. In association with Dr. Rayson of Medical Oncology, Dr. Imran has established monthly neuroendocrine tumor rounds attended by Surgeons, Pathologists, Radiation Oncologists and Radiologists to discuss difficult cases. Dr. Imran in association with Medical Informatics, Family Medicine and Psychology has received a CIHR grant to develop a computerized decision support module for family physicians dealing with chronic disease (diabetes). Dr. Ransom continues to serve as Medical Director with Partners for Healthier Weight (PfHW). PfHW is the first medically and psychologically focused obesity management centre in Atlantic Canada. Their multidisciplinary team of healthcare professionals includes psychologists, physicians, dietitians, nurses, and physiotherapists. Work for the Nova Scotia Department of Health and Wellness Drs. Ransom and Tugwell serve as members of the Diabetes Care Program of Nova Scotia. Quality and Patient Safety Divisional Morbidity & Mortality (M&M) Rounds were continued in 212/13, with two formal M&M rounds annually. Shadow Charts The Division of Endocrinology, in consultation with Health Information Services was able to eliminate shadow charts as of January 213. Provision of access to health information in other District Health Authorities has enabled division members the access needed for safe, efficient patient care. Public Education Drs. Kaiser and Tugwell are members of the Halifax Osteoporosis Club. Dr. Imran is a contributor to the Atlantic Acromegaly Support Group, and has given a Thyroid Cancer Public Awareness lecture in the past year. 5 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM

57 Clinical Services The Endocrinology Division provides specialized inpatient and ambulatory care for patients in the Capital District Health Authority and tertiary care for the region. This includes: General Endocrine Inpatient Consult Service Diabetes Management Centre General Endocrine Clinic (including Diabetes consultation) Lipid Clinic Halifax Neuropituitary Program Emergency Coverage Endocrinologists provide 24 hour, 7 day emergency and consultative coverage for the Queen Elizabeth II Health Sciences Centre (QEII HSC). All full-time division members are incorporated into the call schedule. Inpatient Services There are no designated in-patient beds for Endocrinology within the QEII HSC. Emergency patients are admitted though the Emergency Department under Internal Medicine or other services, and Endocrinologists act on a consultative basis. Inpatient Consultations Endocrinology provides an in-patient consultation service to the QEII HSC at the Halifax Infirmary Site (HI), Victoria General (VG) Site, Veterans Memorial Building, Abbie Lane Building, Nova Scotia Rehabilitation Centre (NSRC) site, and to adults at the neighboring IWK Health Centre. The HI and VG Sites continue to account for the majority of inpatient consults. The total inpatient consultations for 212/13 were 528 as reported by physician services; this data includes all inpatient services by division members, including attending service on the Medical Teaching Units (MTU) and Senior Internist in the QEII HSC Emergency Department. DIVISION OF ENDOCRINOLOGY & METABOLISM Osteoporosis Clinic and Education Class Rapid Consult Clinic Surgical Endocrinology Clinic Thyroid Biopsy Clinic Interdisciplinary Thyroid Oncology Clinic (ITOC) Provide Advice to QEII HSC Diabetes Case Managers In 212/13, endocrinologists provided 4 weeks of attending physician service to the Department of Medicine s Medical Teaching Unit (MTU), 4 weeks of attending service as the Senior Internist in the Emergency Department and 3 weeks (21 shifts) as Internist On-Call to the QEII HSC Emergency Department. This contribution provides a skilled physician resource to care for patients requiring acute medical care, and also provides an opportunity for endocrinologists to play a role as educators in the acute medicine teaching program. Diabetes in Pregnancy Clinic at IWK Health Centre DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM 51

58 DIVISION OF ENDOCRINOLOGY & METABOLISM Ambulatory Care QEII Health Sciences Centre Endocrinology division members participate in seven ambulatory care clinics at the QEII HSC, which include a General Endocrine, Lipid, Neuropituitary, Osteoporosis, Surgical Endocrinology, Thyroid Biopsy and Thyroid Oncology Clinic. Several clinics offer interdisciplinary care, which includes multiple care providers (Registered Dieticians, Certified Diabetes Educators) and specialties (General Surgery, Neurosurgery, Radiation Oncology). There were a total of 7,737 patients registered in endocrinology ambulatory clinics during the 212/13 year; this figure includes visits to physicians, residents, nurses and dieticians. When patients see multiple providers during a visit, they are registered once. Total endocrinology visits to the QEII HSC represent a 21.8% increase from the previous year, due in part to the recent recruitment of Drs. Tugwell and Yip. A breakdown by clinic type is provided below. It should be noted that historical numbers for research have been revised as these were understated. There were an additional 1,253 chart checks performed in 212/13 not included in the following figures. Figure 1 Endocrinology Clinics Ambulatory Care Registrations Capital District Health Authority, Registrations 9, 8, 7, 6, 5, 4, 3, 2, 1, Thyroid Biopsy Clinic Endocrine Insulin Pump Clinic Cobequid Endocrinology Osteoporosis Clinic Endocrinology Thyroid Cancer Endocrinology Surgery Clinic Neuropituitary Research Endocrinology , Osteoporosis Education Endocrinology Function Endocrinology Lipid Clinic General Endocrine 3,411 3,895 3,797 2,862 4,331 Total 6,764 7,283 7,118 6,353 7, DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM

59 General Endocrine Clinic The volume of visits to the General Endocrine Clinic at the QEII HSC from is reflected in the graph below. Some of the more common disease seen in the General Endocrine Clinic includes diabetes (all types) and thyroid function disorders. Data includes visits to physicians as well as separate visits to the Diabetes Education Team that provides on-site education to the more complicated diabetic population being referred to an Endocrinologist for consultation. There were 4,331 patients registered to the General Endocrine Clinic in 212/13, which represents a 51.3% increase compared to the previous year. 3.8% of patient visits to this clinic were new, which continues to be a reflection of the Divisions ongoing efforts to increase consult throughput by arranging follow-up visits with primary care providers and the community Diabetes Management Centres when appropriate. Figure 2 General Endocrine Clinic Ambulatory Care Registrations 5 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total , , , , ,331 Figure 3 Lipid Clinic The volume of lipid clinic visits over the past 5 years is reflected in the graph below. The Endocrinology Heart Health clinic transitioned to the Endocrinology Lipid Clinic in November 24. Data includes visits to both the physician and lipid dietician. There were 46 visits registered to the Lipid Clinic in 212/13, which represents a 2.% increase compared to the previous year. Of the total visits in 212/13, 33.% were new consults. Figure 4 Endocrinology Lipid Clinic Ambulatory Care Registrations DIVISION OF ENDOCRINOLOGY & METABOLISM General Endocrine Clinic New and Return Ambulatory Care Registrations 5, Registrations 4,5 4, 3,5 3, 2,5 2, 1,5 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total , New 1,3 1,475 1, ,335 Return 2,111 2,42 2,549 1,9 2,996 Total 3,411 3,895 3,797 2,862 4,331 % New 38.1% 37.9% 32.9% 33.6% 3.8% DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM 53

60 DIVISION OF ENDOCRINOLOGY & METABOLISM Figure 5 Endocrinology Lipid Clinic New and Return Ambulatory Care Registrations 5 Registrations New Return Total % New 29.7% 3.9% 29.3% 27.4% 33.% The volume of patients seen in the Halifax Neuropituitary Program (HNP) since 28/9 is reflected in the graph below. Total registrations include visits to both the weekly Medical Pituitary Clinics, attended by Endocrinology, as well as the biweekly Surgical/Stereotactic Radiation Therapy (SRT) clinics where patients are consulted by Endocrinology, Neurosurgery, Radiation Oncology and Otolaryngology; all encounters are captured through a single registration. There were 718 patients seen in the 212/13 fiscal year, which represents a 13.1% increase from the previous year. Figure 6 Endocrinology Neuropituitary Ambulatory Care Registrations 12 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Figure 7 Endocrinology Neuropituitary New and Return Ambulatory Care Registrations QEII Health Sciences Centre, Registrations Endocrinology Surgery Clinic The volume of patients seen in the monthly interdisciplinary Endocrinology Surgery Clinic since 28/9 is reflected in the graph below. Clinic visits are captured through a single registration and, in the majority of cases, include interaction with a multidisciplinary team: an Endocrinologist, General Surgeon and Otolaryngologist. There were 98 patients seen in the 212/13 fiscal year, which represents a 1.9% decrease from the previous year. Of the total visits in 212/13, 51.% were new consults. Figure 8 Endocrinology Surgery Ambulatory Care Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Registrations New Return Total % New 2.5% 21.4% 21.4% 24.6% 16.7% 54 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM

61 Figure 9 Endocrinology Surgery New and Return Ambulatory Care Registrations 25 Registrations New Return Total % New 64.8% 61.5% 48.% 43.6% 51.% Osteoporosis Clinic In 212/13, there were a total of 416 patients seen in the Osteoporosis Clinic, which represents no change from the previous year. Of the visits to the Osteoporosis Clinic in 212/13, 36.1% were new consults. In addition to visits to the Osteoporosis Clinic, 47 visits were registered to Osteoporosis Education Class during the 212/13 fiscal year, representing a 28% decrease from the previous year. Figure 1 Endocrinology Osteoporosis Clinic Ambulatory Care Registrations 7 Figure 11 Endocrinology Osteoporosis Clinic New and Return Ambulatory Care Registrations 5 Registrations New Return Total % New 33.6% 35.9% 32.4% 42.2% 36.1% DIVISION OF ENDOCRINOLOGY & METABOLISM 6 5 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM 55

62 DIVISION OF ENDOCRINOLOGY & METABOLISM Interdisciplinary Thyroid Oncology Clinic (ITOC) The ITOC began in October 26. As the first clinic of its kind in Canada, thyroid cancer patients who have completed full thyroidectomy consult with Endocrinology, Radiation Oncology, Nuclear Medicine and Nursing in a single, coordinated clinic visit. Of note, the innovative ITOC was the 29 recipient of the Cancer Care Nova Scotia Excellence in Clinical Care Award. There were 429 visits registered to the ITOC in 212/13, representing a 1.8% increase from the previous year. Of the visits to the ITOC in 212/13, 16.6% were new consults. Figure 12 Figure 13 Thyroid Oncology Clinic New and Return Ambulatory Care Registrations 5 Registrations New Return Total % New 22.9% 2.3% 19.7% 21.2% 16.6% Thyroid Biopsy Clinic The monthly Thyroid Biopsy Clinic began as a partnership between Endocrinology and Pathology in August 23. Visits to the clinic prior to November 29 are reported with General Endocrine Clinic data in Figure 2; as of November 29 visits are now registered separately. There were 14 clinic visits registered during 212/13, of which 57.1% of patients were new consults. Figure 14 Thyroid Biopsy Clinic Ambulatory Care Registrations QEII Health Sciences Centre, November 29 - March Thyroid Oncology Clinic Ambulatory Care Registrations Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Note: In November 29, data specific to the Thyroid Biopsy clinic began to be collected. Prior to this period, Thyroid Biopsy registrations were included in the General Endocrine Clinic Volumes. 56 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM

63 Figure 15 Thyroid Biopsy Clinic New and Return Ambulatory Care Registrations QEII Health Sciences Centre, November 29 - March Registrations New Return Total % New 78.9% 73.9% 6.9% 57.1% Special Service Commitments The Endocrinology division provides special service commitments at the IWK Health Centre; two Endocrinologists attend a weekly Pregnancy in Diabetes Clinic on a rotational basis. A total of 52 Pregnancy and Diabetes visits occurred at the IWK Health Centre in 212/13, which represents an 11.6% decrease from the previous year. Figure 17 Endocrinolgy Pregnancy and Diabetes Registrations IWK Hospital, Diabetes Management Centre Endocrinologists provide clinical support to the Nova Scotia Diabetes Management Centers; Dr. Tugwell has served as Medical Director since joining the Division in February 212. The breakdown by centre is illustrated below. There were a total of 12,143 registrations to the Diabetes Management Centers across the Capital District in 212/13, representing a 7.4% decrease from the previous year. This figure does not include visits to the Diabetes Education Team in Endocrinology Clinic at the QEII HSC; that data is reported above. Figure 18 DIVISION OF ENDOCRINOLOGY & METABOLISM Ambulatory Care Cobequid Community Health Centre (CCHC) The division began a monthly General Endocrine Clinic at the Diabetes Management Centre at Cobequid Community Health Centre in September 27. There were 91 visits registered to the Cobequid Endocrinology Clinic in 212/13, representing a 16.9% increase from the previous year. Figure 16 General Endocrine Clinic Ambulatory Care Registrations Cobequid Community Health Centre, September 28 - March Registrations S. Gee T. Ransom Total Source: Meditech Diabetes Care Ambulatory Care Registrations Capital Health, , Registrations 1, 5, Duffus Diab Educ Twin Oaks Diab Educ Musq Valley Diab Educ Hants Comm Diab Educ 935 1,225 1, Eastern Shore Diab Educ Dartmouth Diab Educ 3,186 2,943 2,987 3,291 3,13 Cobequid Diab Educ 3,554 3,576 3,239 3,82 2,859 Bayers Road Diab Educ 4,913 5,22 5,158 4,529 4,136 Total 13,26 14,271 13,692 13,118 12,143, DCPNS Data *Bayers Road Diabetes Education Centre formerly 5 Bethune at QEII HSC Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM 57

64 DIVISION OF ENDOCRINOLOGY & METABOLISM Ambulatory Care Wait Lists Managing wait times is a major priority for the division. The table below shows the triage criteria used for new referrals to Endocrinology outpatient clinics in 212/13. Table 1 Triage Guidelines for New Referrals to Endocrinology Outpatient Clinics Emergent Examples include: Diabetic ketoacidosis Severe hypoadrenalism Severe hypercalcaemia Urgent Category A Examples include: Diabetes A1c >12 (new or different) Newly diagnosed Type 1 diabetes mellitus Hypercalcaemia > 3. Hyperlipidemia TG >1 Hypoadrenalism Hypopituitarism Diabetes Insipidus Severe Hyperthyroidism Semi-Urgent Category B Examples include: Hyperthyroidism and Severe Hypothyroidism Pituitary tumor Thyroid lump Diabetes A1c >1 Hyperlipidemia high risk Hypercalcaemia Endocrine Hypertension Non-Urgent Category C Others Standard Wait Time Within 24 hours (1 day) Within 1 week (7 days) Within 4 weeks (28 days) Within 16 weeks (112 days) Wait times by quarter are published on the Dalhousie Department of Medicine website. Aggregate triage category wait graphs include new consults to all Endocrine clinics, excluding Endocrinology Surgery as this service is triaged and scheduled by Department of Surgery. The following data illustrate wait times per quarter for consults within each triage category from Figure 19 Endocrinology New Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait 1 2 Maximum Wait % Within Standard 68% 88% 52% 64% 49% 56% 6% 72% Source: PHS Data Figure 2 Endocrinology New Semi-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 37% 7% 19% 18% 3% 33% 46% 39% Source: PHS Data 58 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM

65 Figure 21 Endocrinology New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 68% 4% 23% 27% 34% 5% 74% 79% Source: PHS Data Figure 23 Neuro Pituitary Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 67% 86% 86% 82% 83% 7% 1% 79% Source: PHS Data Figure 25 Lipid Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 5% % 4% 14% 33% 13% 2% 41% Source: PHS Data DIVISION OF ENDOCRINOLOGY & METABOLISM Figure 22 Figure 24 General Endocrinology Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Osteoporosis Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 72% 42% 16% 15% 22% 46% 68% 78% Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 19% 6% 1% 22% 46% 68% 93% 88% Source: PHS Data Source: PHS Data DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM 59

66 DIVISION OF ENDOCRINOLOGY & METABOLISM Clinic No Shows The number of No Shows for endocrinology clinic appointments has been consistent over the past few years. There were 55 no shows to Endocrinology clinics over 212/13. The no-show rate for the division was 8.4%, which is slightly lower than the figure of 9.8% from the previous year. 32.2% of the no-shows that occurred were for new appointments. The data below indicate no-shows for physician visits in 212/13: Table 2 Endocrinology No-Show Rates 212/13 - PHS Physician Booked No Show % No Show % New % Return AI 1, % 19.5% 8.5% BT 1, % 29.4% 7.6% Distribution of Patients by District 18.9% of patients seen in Endocrinology Clinics at the QEII HSC and 11.% of patients seen at CCHC were from outside the Capital Health District. The Endocrinology service targets a 33% proportion of patients from outside Capital Health by focusing on discharging patients (mainly from Capital District) that receive more of a primary/ secondary care intervention. The following data excludes Endocrine Surgery and chart check registrations. Figure 26 Endocrinology Clinic Registrations Distribution of Patient Residency by Health District CY % 62.9% 37.1% SG % 24.5% 75.5% SK % 38.2% 61.8% TR 1, % 41.% 59.% Total 6, % 32.2% 67.8% Other: 6 NB, NF, PEI: 3 SWH: 94 SSH: 167 PCHA: 9 GASHA: 25 CHA: 27 CEHHA: 325 CBDHA: 41 AVDHA: 147 CDHA: 4,86 6 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM

67 Figure 27 Endocrinology Clinic Registrations Summary Distribution of Patient Residency by Health District Cobequid Community Health Centre, Non Capital District: 1 Capital District: 81 Distribution of Patients by Age and Gender Education Dr. Stephanie Kaiser continues as Subspecialty Program Director, and Dr. Ransom oversees Undergraduate Education. Drs. Ransom and Tugwell provided MTU/ED coverage on behalf of the Division of Endocrinology in 212/13. Undergraduate Medical Education 8 clinical clerks, including 1 elective, did 4-week rotations through the division in the 212/13 academic year. Division members delivered 24 hours of Med I & 2 Case Based Learning (CBL), 12 hours of Med II Consolidated Clinical Skills, 2 hours of lecturing in the Med 2 to 3 IMU Link Program, hours as examiners for Med 2 & 3 OSCE and 8 hours of Clerkship Seminars in the 212/13 academic year. Sub-specialty Medical Education The Division offers a sub-specialty-training program accredited by the Royal College of Physicians and Surgeons of Canada. There were 3 sub-specialty residents enrolled in the program in 212/13. Dr. AlOtaibi completed training in October 212 and is working at Al-Adan Hospital in Kuwait. Dr. AlDhamani completed his training in June 213 and will undertake a Pituitary Fellowship with the Division in 213/14. Continuing Medical Education Endocrinologists were active in the provision of continuing medical education, with 17 sessions presented to general practitioners, specialists, endocrinologists and other health professionals. DIVISION OF ENDOCRINOLOGY & METABOLISM Figure 28 Total Endocrinology Clinic Registrations Percent Distribution by Age and Gender Age Group 9+ 3.% % 22.1% 14.9% 15.5% 5.4% 13.1% 13.1% 18.9% 21.2% Postgraduate Medical Education 29 residents from various disciplines, including Nuclear Medicine, Obs/Gyn, Psychiatry and Ophthalmology rotated through the Endocrinology service for 4 weeks each during the 212/13 academic year. Division members delivered 9 hours of Academic Half- Day and 5 hours of CaRMS File Review in the 212/13 academic year % 19.1% % 7.8% % 1.6% -19.2%.1% 5.% 4.% 3.% 2.% 1.%.% 1.% 2.% 3.% 4.% 5.% Female Male DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM 61

68 DIVISION OF ENDOCRINOLOGY & METABOLISM Research The Endocrine Research group continues to be very active, participating in a number of important peer-reviewed funded clinical trials, as well as significant contract research activity. Dr. Imran continues with his basic research activities. Dr. Kaiser has been actively involved in osteoporosis research and has been active in the Canadian Multicentre Osteoporosis Study (CaMos). Endocrinologists supervised 5 students/residents/ learners in directed research projects during the period of September 1, 212 August 31, 213. Division members published 6 peer-reviewed papers and participated in 13 abstract and research presentations in 212/13. The Division generated $629,776 in research grants and industry contracts during 212/13. Administration The division members were involved in the following administrative activities: Division Head/Service Chief, including all responsibilities of the position. Division members act as Directors/Head/Chairs for: Chair, Division of Endocrinology Business Committee Chair, Division of Endocrinology M&M Rounds Committee Chair, Division of Endocrinology Clinical Research Committee Chair, Division of Endocrinology Residency Training Committee Chair, Canadian NeuroPituitary Network Co-Chair, Canadian Diabetes Association/Canadian Society of Endocrinology and Metabolism President-Elect, Canadian Society of Endocrinology and Metabolism Medical Director, Bariatric Surgery Committee Medical Director, Diabetes Centre Medical Director, Halifax Neuropituitary Program Medical Director, Lipid Clinic Medical Director, Osteoporosis Centre Medical Director, Thyroid Oncology Clinic Medical Director, Partners for Healthier Weight Program Director, Endocrinology Residency Training Program Division members provided referee or editorial services to 12 journals/granting agencies in 212/ DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF ENDOCRINOLOGY & METABOLISM

69 Division of General Internal Medicine DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE 63

70 DIVISION OF GENERAL INTERNAL MEDICINE Physician Resources 16 General Internists (8.1 FTE) 5 Full-Time 11 Part-Time Divisional Highlights Dr. Mann became president of the College of Physicians and Surgeons of Nova Scotia in Spring 212. Drs. Rebello and Workman both received the Excellence in Medical Education Award in June 212. Dr. Haroon received a Professional Kudos Award from the Professionalism Committee in the Faculty of Medicine in May 213. Dr. Simpson received the Department of Medicine Achievement Award in June 213. Dr. Krueger-Naug joined the division on a part-time basis in August 212. Dr. Haroon joined the division on a part-time basis in September 212. Dr. Cookey retired from the division in June 212, and Dr. O Brien retired in September 212. New Programs and Initiatives In 212/13, Dr. Haroon was responsible for initiating and developing a robust new program in simulation for the core Internal Medicine residency. Simulation is widely recognized to be of great importance and Dr. Haroon was appointed to be the representative for simulation on the Internal Medicine Residency Training Committee. He and several colleagues including three from the Division of General Internal Medicine, and one from the Division of Respirology have been conducting regular training in simulation for the residents. Dr. Haroon has met with rave reviews for the initiation of this important topic in medical education that had hitherto been lacking and to the quality of the sessions that were being provided. In June 213, Dr. Haroon developed the inaugural 3-day Boot Camp for Internal Medicine PGY1 residents about to start their residency. This initiative involved didactic sessions on residents as teachers, feedback and evaluation, providing handover, critical thinking in medicine, and code status discussion. Several faculty members and two senior residents presented these sessions that occurred during a half day. Two subsequent full days of Boot Camp were spent on hands-on experience with high fidelity task trainers and cadavers for learning medical procedures as well as simulation of acute medical emergencies using the 3G SIM MAN. This is the first time such a program has ever been developed in the Department of Medicine and is intended to ease the transition from clinical clerkship to residency. There is every expectation that the quality of care delivered to patients by these residents will be significantly enhanced by this initiative. In June 213 discussions began with Capital Health about the initiation of an electronic discharge summary on the Medical Teaching Unit (MTU). Previously, the interim discharge summary had been a handwritten document that was at times difficult to read. This new initiative allows for a legible discharge summary to reach the family physician much more expeditiously than dictated discharge summaries and is also expected to improve patient safety. Through recruitment the division ultimately aims to expand their outpatient services through: Establishing a formal Perioperative Clinic that can see consults in a timely fashion on referral from surgeons; Establishing a Complex Care Clinic to reduce readmissions to MTU and enhance end of life care; Develop more robust Hypertension and Congestive Heart Failure Clinics to improve accessibility for patients and to increase research activities in these areas; and collaborate with colleagues in Neurology, Endocrinology, Cardiology/Cardiovascular Surgery, Vascular Surgery, and Vascular Interventional Radiology and expand the Vascular Medicine Clinic for appropriate patients. Additionally, the Division plays a major role in the Medical Teaching Unit and believes that the best system for the learners would be to have an equal number of Subspecialists attending with General Internal Medicine staff on any given rotation. They also believe that General Internists are the ideal individuals to work in the Emergency Department (ED) as the Senior Internist. Due to current staffing shortages and other clinical obligations over the past few years, members have not been able to staff 5% of the MTU rotations or Senior Internist positions. With appropriate recruitment the Division believes General Internists should fill 5% of MTU positions and 8-9% of Senior Internist positions. 64 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE

71 Quality and Patient Safety The recent development of a robust simulation program for Internal Medicine residents will improve their ability to perform a number of invasive procedures in a safer manner. Simulation training in how to deal with acute medical emergencies will also be expected to result in improved patient outcomes when the residents are dealing with real acute crisis in medical patients. A monthly resident-driven Medical Teaching Unit morbidity and mortality round was initiated in January 213. The cases presented usually focus specifically on issues of patient safety and are discussed by all of the house staff and the attending staff on the MTU. The focus is to improve quality and patient safety. A pilot project to involve pharmacy technicians in the Emergency Department from 8: am until midnight was also implemented in 212/13. Their role was to obtain the best possible medication history, which is very critical for medication reconciliation. It is anticipated that there will be a marked reduction in medication error because of this initiative and this, of course, has very important implications for patient safety. Division members review all in-patient deaths on the Medical Teaching Units at monthly mortality rounds. Average Length of Stay A new initiative was developed on the MTU in October 212 to reduce the average length of stay. Bullet Rounds are brief rounds that occur daily during the week to try to identify anticipated date of discharge and to discuss and try to resolve impediments to discharge. These rounds are attended by all members of the allied multidisciplinary team as well as member of the medical team. They are designed to be brief and focused on the goal of reducing length of stay. Clinical Services Specialized acute internal medicine care is provided for patients at Capital Health (including Dartmouth General Hospital). General Internal Medicine Clinics General Internal Medicine General Clinic Hypertension Clinic Congestive Heart Failure Clinic Immunology Clinic /Testing Vascular Risk Reduction Clinic Hypertension Education Program Other Commitments include: Medical Teaching Unit Attending Coverage (MTU) Intermediate Care Unit (IMCU) Senior Internist to QEII Emergency Department General Internal Medicine Consultation Service Hyperbaric Medicine Unit DIVISION OF GENERAL INTERNAL MEDICINE MTU- Medical Teaching Unit The Department of Medicine provides attending service to a maximum of 46 MTU beds as well as in-house consultative service to the QEII HSC Emergency Department. There are 2 acute care inpatient MTU teams at the Halifax Infirmary site, as well as the affiliated Intermediate Care Unit (IMCU) providing care for residents of Capital Health District and some tertiary care services for residents outside the district. The MTU service coverage is divided into 26, 2-week rotations. The Division of General Medicine provided 44 weeks of attending physician service in 212/13. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE 65

72 DIVISION OF GENERAL INTERNAL MEDICINE Senior Internist in Emergency Department The Department of Medicine continues to provide in-house consultative service to the Emergency Department through the Senior Internist role. The Division of General Internal Medicine provided 27 weeks of attending service to the Senior Internist rotation in 212/13. Additionally, division members contributed 7 weeks of evening/weekend/holiday shifts as Internist On-Call to the ED. Special Service Commitments Staff physicians within the Division of General Medicine make significant contributions to programs operated outside the Division. 2 weeks of IMCU (24/7) coverage in the 212/13 academic year. Inpatient Consultations Division members provide a General Internal Medicine Inpatient Consult Service to the Victoria General, Halifax Infirmary, Nova Scotia Rehab Centre and IWK Health Centre. Community-based division members provide consultative service to Dartmouth General. Data on inpatient consults by all division members in 212/13, as reported by Physician Services, is shown below. This data includes all inpatient services by division members, including attending service on the MTU, IMCU and Senior Internist role. There were 1,98 inpatients seen in consultation between April 1, 212 and March 31, 213. Figure 1 Ambulatory Care The General Internal Medicine Ambulatory Clinics at the QEII HSC registered 4,471 visits in 212/13, representing a 1.3% decrease from the previous fiscal year. The division has instituted a standard triage process which has further enhanced their urgent ambulatory consult service. General Internal Medicine Ambulatory visits are registered under General Medicine, Hypertension, Heart Failure, Immunology and Vascular Risk Reduction clinics. The following graphs provide a breakdown of the registrations within each of these clinics between 28/9 and 212/13. There were an additional 499 chart checks performed in 212/13 not included in the following figures. 96 (24 hour) on-call rotations to the Hyperbaric Medicine Unit. General Internal Medicine Inpatient Consults Capital Health, , 12, 1, Figure 2 General Internal Medicine Clinics Ambulatory Care Registrations 6, Inpatient Consults 8, 6, 4, 2, Registrations 5, 4, 3, 2, 1, New 2,796 2,614 2,66 2,174 1,953 Return 8,735 6,877 6,263 7,35 7,599 Total 11,531 9,491 8,869 9,29 9,552 Source: MOM Data GM Vascular GM Heart Failure GM Immunology GM Hypertension 2,57 2,327 2,3 1,427 1,362 General Medicine 1,855 1,881 2,174 2,15 2,146 Total 5,189 5,496 5,368 4,529 4, DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE

73 General Medicine Clinic The General Medicine general clinic registered 2,146 visits in 212/13, which represents a.2% decrease from the previous year. Of the visits registered in 212/13, 49.7% were new consults. Figure 3 General Internal Medicine New and Return Ambulatory Care Registrations 2,5 Registrations 2, 1,5 1, Code Missing New ,152 1,52 1,67 Return ,19 1,94 1,75 Total 1,855 1,881 2,174 2,15 2,146 % New 49.9% 52.3% 53.% 48.9% 49.7% Hypertension Clinic The Hypertension Service registered 1,362 visits in 212/13, which represents a 4.5% decrease from the previous year. Of these visits, 14.8% were new consults. The Hypertension Education Nurse registered 432 outpatient visits for ambulatory blood pressure monitoring at the QEII HSC. Hypertension Education is provided at the QEII HSC, Cobequid Community Health Centre and Dartmouth General Hospital; this data is reported later in this document. The Hypertension Nurse Practitioner (NP) registered 641 visits including both new and return patients in 212/13. This represents a 6.9% increase from volumes seen the previous year. The NP and internist collaborate on this patient population as necessary, and the physician personally reviews any difficult cases. The Hypertension Physicians registered 289 visits in 212/13. Overall physician registrations to the hypertension service saw a 1.4% decrease from the previous fiscal year. Congestive Heart Failure Clinic (CHF) The CHF Clinic saw 663 visits in 212/13, which represents a 5.6% increase from the previous fiscal year. Of the total visits in 212/13, 6.9% were new consults. Patients in the CHF Clinic are followed by an NP who regularly makes home visits and nursing home visits thereby markedly reducing readmission and mortality rates for CHF patients. New patients are reviewed in detail with an attending internist. The NP and internist collaborate on this patient population as necessary, and the physician personally reviews any difficult cases. Figure 5 General Internal Medicine Congestive Heart Failure New and Return Ambulatory Care Registrations 8 Registrations DIVISION OF GENERAL INTERNAL MEDICINE Figure 4 General Internal Medicine Hypertension New and Return Ambulatory Care Registrations 2, Code Missing New Return Total % New 16.3% 16.2% 1.4% 11.1% 6.9% 2, Registrations 1,5 1, Code Missing New Return 1,753 2,44 1,714 1,243 1,16 Total 2,57 2,327 2,3 1,427 1,362 % New 14.8% 12.2% 12.6% 12.9% 14.8% DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE 67

74 DIVISION OF GENERAL INTERNAL MEDICINE Immunology/Allergy Clinic The Immunology Clinic had 97 visits in the 212/13, which represents a 12.6% decrease from the previous year. Drs. Lacuesta and Connors focus their QEII HSC ambulatory service on specialty testing (i.e. venom) for patients initially seen in their community practice. Additionally, Dr. LindenSmith continues to accept referrals for adult immunology in the DGH General Internal Medicine Clinic. Of note, new visits in Figure 6 represent patients new to the QEII Immunology Clinic, and not new referrals to the Community-Based Internists that attend these clinics. Figure 6 General Internal Medicine Immunuology New and Return Ambulatory Care Registrations 25 Vascular Risk Reduction Clinic The Vascular Risk Reduction Clinic provides medical management of cardiovascular risk factors to patients with Peripheral Arterial Disease (PAD). Following referral from Vascular Surgery, patients are seen by an Internist and a Vascular Surgery Nurse Practitioner (NP). Patients are registered to an Internal Medicine Physician on their initial visit and on occasions where the physician may need to see them in follow-up. Otherwise, all follow-up visits are registered to the NP. Members of the Division of General Internal Medicine attend this clinic on a rotational basis. There were 23 visits to the Vascular Clinic in 212/13, which represents a 4.7% decrease from the same period last year. Figure 7 Medical Day Unit In addition to the clinic registrations, 911 General Internal Medicine outpatients were seen in the Medical Day Unit in 212/13, which represents a 29.6% increase from the previous year. Figure 8 General Internal Medicine Other Ambulatory Care Registrations 1, Registrations Registrations Code Missing New Return Total % New 71.9% 47.8% 3.4% 12.6% 13.4% General Internal Medicine Vascular Risk Reduction Clinic Ambulatory Care Registrations 7 Registrations Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Total Minor Proc Unit PatFam Learn Med Day Unit Total DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE

75 Ambulatory Care Dartmouth General Hospital (DGH) The General Internal Medicine Clinic at the DGH registered 1,4 visits in 212/13, which represents a 17.2% increase from the previous fiscal year. Of these visits, 3.8% were new consults. Figure 9 General Internal Medicine New and Return Ambulatory Care Registrations Dartmouth General Hospital, ,2 Registrations 1, Ambulatory Care Cobequid Community Health Centre (CCHC) A General Medicine Ambulatory Care Service was reopened at Cobequid Community Health Centre in November 27. There were 16 registrations in 212/13. Figure 1 General Internal Medicine New & Return Ambulatory Care Registrations Cobequid Community Health Centre, Registrations Ambulatory Care Wait Lists Wait times are published on the Department of Medicine website each quarter. During the 4 th quarter of 212/13, average wait times for urgent, semi-urgent and non-urgent consultations to the General Internal Medicine Clinics were within standard. On average, 4th quarter wait times for routine consults to the General Medicine and Hypertension Clinics exceeded standard. The following (4) graphs represent aggregate wait times for new consults to the General Medicine, Hypertension and Heart Failure clinics across the three triage categories: Figure 11 General Internal Medicine Ambulatory Care Clinic Average Wait Time (Days) QEII Health Sciences Centre, January - March DIVISION OF GENERAL INTERNAL MEDICINE Code Missing New Return Total ,4 % New 38.9% 33.7% 34.1% 32.% 3.8% Return New % New 49.7% 61.3% 48.3% 4.5% 38.7% Total Days Urgent Semi-Urgent Non-Urgent Standard Wait Time Average Wait Time Count Minimum Wait 2 Maximum Wait % Within Standard 83% 88% 86% Source: PHS Data DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE 69

76 DIVISION OF GENERAL INTERNAL MEDICINE Figure 12 General Internal Medicine New Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait 1 1 Maximum Wait % Within Standard 79% 76% 75% 75% 72% 75% 89% 83% Source: PHS Data Figure 13 General Internal Medicine New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Figure 14 General Internal Medicine New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 93% 63% 37% 41% 39% 58% 72% 86% Source: PHS Data The following (2) graphs represent individual average wait times for routine new consults to the General Medicine and Hypertension subspecialty clinics: Figure 15 General Internal Medicine General Medicine Routine Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 94% 52% 23% 24% 32% 53% 73% 89% Source: PHS Data Figure Days General Internal Medicine Hypertension Routine Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 89% 65% 77% 81% 83% 81% 83% 88% Source: PHS Data Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 92% 63% 25% 6% 38% 31% 57% 76% Source: PHS Data 7 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE

77 The following graphs represent individual average wait times for General Medicine Clinics at Dartmouth General Hospital. Figure 17 General Internal Medicine New Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter Dartmouth General Hospital, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 75% 5% 1% 67% 1% 1% 1% Source: PHS Data Figure 19 General Internal Medicine New Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter Dartmouth General Hospital, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 23% 6% 2% 7% 11% 18% 48% 47% Source: PHS Data No Shows Procedures by Resources Unit April 212 to March 213 QEII Health Sciences Centre, General Internal Medicine Resource Booked No Show % No Show Benoit, Rosalind % Connors, Lori A 11.% Haroon, Babar A % Jayasinghe, Jackie % Krueger-Naug, Anne Marie % Lacuesta, Gina A % Mann, Beth % Manning, J David % DIVISION OF GENERAL INTERNAL MEDICINE Figure 18 Figure 2 Parkash, Rajender % Rebello, Rosario % General Internal Medicine New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter Dartmouth General Hospital, Days General Internal Medicine Immunology Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter Dartmouth General Hospital, Days Simpson, C David % Workman, Stephen % Total 3, % Source: PHS 2 1 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 33% 1% 14% 1% 14% 42% 61% 21% Source: PHS Data 5 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard % % 8% % 2% % 47% 17% Source: PHS Data Procedures by Resources Unit April 212 to March 213 Dartmouth General Hospital, General Internal Medicine Resource Booked No Show % No Show LindenSmith, Jorin % Zaman, Khawar-Uz % Total 1, % Source: PHS DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE 71

78 DIVISION OF GENERAL INTERNAL MEDICINE Distribution of Patients by District 7.9% of visits to the General Internal Medicine Clinic in 212/13 were patients who reside outside the Capital Health District. Figure 21 General Internal Medicine Clinic Registrations Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, Out of Province: 7 2.% of visits to the CHF Clinic in 212/13 were patients who reside outside the Capital Health District. Figure 23 General Internal Medicine Heart Failure Clinic Registrations Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, Non Capital District: % of visits to the Dartmouth General Internal Medicine Clinic were patients who reside outside the Capital Health District. Figure 25 General Internal Medicine (AFP) Clinic Registrations Summary Distribution of Patient Residency by Health District Dartmouth General Hospital, Non Capital District: 25 Non Capital District: 162 Capital District: 1,977 Capital District: 65 Capital District: 1, % of visits to the Hypertension Clinic in 212/13 were patients who reside outside the Capital Health District. Figure 22 General Internal Medicine Hypertension Clinic Registrations Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, % of visits to the Immunology/Allergy Clinic are patients who reside outside the Capital Health District. There are no certified adult immunologists outside of HRM therefore this referral pattern is appropriate. Figure 24 General Internal Medicine Immunology Clinic Registrations Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, Out of Province: % of visits to the Cobequid Community Health Centre Clinic were patients who reside outside the Capital Health District. This ratio is encouraging given CCHC consults are being offered to patients who reside outside of HRM, in order to ease the burdens of travel and available parking. Figure 26 General Internal Medicine Clinic Registrations Summary Distribution of Patient Residency by Health District Cobequid Community Health Centre, Out of Province: 6 Non Capital District: 26 Non Capital District: 24 Non Capital District: 153 Capital District: 1,23 Capital District: 67 Capital District: DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE

79 Education Education remains a strength in the division. General Internists devoted significant time and effort to education in 212/13. Education at all levels occurs as part of the day to day activities of the physicians. Division members contributed tremendously to undergraduate medical teaching, postgraduate medical education and continuing medical education including: Undergraduate Medical Education 35 clinical clerks and 4 undergraduate medical students chose General Internal Medicine as an elective in the 212/13 academic year. An additional 94 clinical clerks rotated through the MTU and MTU/ED in the 212/13 academic year. Division members delivered 116 hours of Med I Clinical Skills, 8 hours of Med I Rotating Elective, 36 hours as tutors for Med I & 2 Case Based Learning (CBL), 36 hours of Consolidated Med II Clinical Skills, 16 hours of Clerkship Seminars (including Critical Care components) and hours as examiners for Med II and III OSCEs. Sub-specialty Medical Education 6 Visiting Professors lectured during GIM PGY4 Academic Sessions in 212/13. Congratulations to Drs. Cornish, Elnaily, Ho, Kim and Van Zoost, who completed their GIM PGY4 year and passed their Royal College Examinations in 212/13. There will be 5 residents enrolled in the GIM Residency Training Program in 213/14. Continuing Medical Education General internists are active in the provision of continuing medical education, with 4 sessions presented in 212/13 to general practitioners, medicine and surgical specialists and other health professionals as well as teaching within other faculties at Dalhousie University. Research 1 abstract was presented at a scientific meeting in 212/13. Referee or editorial services were provided to 3 journals/granting agencies in 212/13. DIVISION OF GENERAL INTERNAL MEDICINE Postgraduate Medical Education All core Internal Medicine residents completed 1 (4 week) blocks of Internal Medicine as part of their Royal College Accredited three year core medical training. 53 residents completed rotations through General Medicine services in 212/13, including 3 Anaesthesia resident rotations. Division members also delivered 3 hours of Academic Half- Day, 1 hours as examiners for Resident OSCE, 5 hours of CaRMS File Review, 4 hours of CaRMS interviews and provided bedside teaching during 44 weeks of attending coverage on the MTU and 2 weeks of attending coverage on the IMCU in 212/13. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE 73

80 DIVISION OF GENERAL INTERNAL MEDICINE Administration Members of the Division of General Medicine continue to be incredibly active in committee work within the Faculty, Department, Hospital, and Division. Members play crucial roles in Royal College committees, and national examining boards. Members in the Division have a broad range of interests and abilities. General Internists performed the following administrative activities: Interim Division Head/Service Chief Program Director, GIM PGY4 Residency Training Program Medical Director, Canadian Forces, ACLS Refresher Course Medical Director, Canadian Forces, ACLS Provider Course President Elect, College of Physicians and Surgeons of Nova Scotia Associate Director, MTU Chair, MTU Evaluations Committee Director, Capital Health Hyperbaric Medicine Unit Director, Hypertension Unit Site Leader, DGH ICU/CCU Director, Med II Clinical Methods Chair, Canadian Society of Internal Medicine: Annual Scientific Meeting Committee Chair, College of Physicians & Surgeons of NS: CAPP Clinical Examination Review Committee Chair, Royal College of Physicians & Surgeons of Canada: Specialty Committee in Internal Medicine 74 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GENERAL INTERNAL MEDICINE

81 Division of Geriatric Medicine DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE 75

82 DIVISION OF GERIATRIC MEDICINE Physician Resources The Division of Geriatric Medicine has a complement of 11 Geriatricians who provide care to those over age 65. In addition, the division includes 1 family physician (.5 FTE) with added competence in Geriatric Medicine. The total complement is 1.5 FTE s. Division Highlights Dr. C. MacKnight received the Service Award from the Alzheimer Society of Nova Scotia in 212/13. In the past years, Dr. K. Rockwood was the recipient of: the Irma Parhad Award for Excellence in Research, the Consortium of Canadian Centres for Clinical Cognitive Research award and the renewed Kathryn Allen Weldon Chair for Alzheimer Research. Improvements to Patient Care The outcomes of the first 15 patients in the The Palliative and Therapeutic Harmonization (PATH) program was published in the Journal of the American Geriatrics Society in 212/13 and showed that those with more advanced frailty or dementia are less likely to choose aggressive treatments. This reduction is patient and family led and is associated with high satisfaction. The PATH Program was recognized with the Deloitte/IPAC gold award, which acknowledges leadership in health care Renal PATH was developed to address frailty in the nephrology clinic, where nurse practitioner David Landry uses the PATH algorithm to review the pros and cons of dialysis when individuals are frail. The Hierarchical Assessment of Balance and Mobility (HABAM) has finally been implemented on the Geriatric Assessment Unit. This daily assessment, developed by Drs. K. Rockwood and C. MacKnight, uses mobility as a vital sign to show whether health is improving or deteriorating. Quality Patient Safety Preprinted orders for the Geriatric Assessment Unit were developed by Dr. Casey Clarkson. Electronic Discharge Medication Reconciliation (edmr) is used routinely on the GAU, PCU and GRC services. New Programs, Partnerships & Innovations A Geriatric Occupational Therapy Pilot was initiated to improve transition from inpatient units to home. Shortly after discharge, patients at high risk of re-admission are seen in their home, where recommendations and requests for support can better reflect care needs. This in turn optimizes their ability to stay at home. The Dartmouth General Hospital consultation service is now well established and Geriatric Outreach clinics continue in Fisherman s Memorial Hospital, Annapolis Valley Regional Hospital, and Cobequid Community Health Centre. 76 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE

83 Work for the Nova Scotia Department of Health and Wellness Drs. C. MacKnight C. and L. Mallery sit on the Polypharmacy Toolkit Working Group with the Guysborough Antigonish Strait Health Authority (GASHA). Dr. L. Mallery is a member of the Atlantic Common Drug Review for Pharmacare. Efforts to Reduce Average Length of Stay The HABAM was recently initiated on the Geriatric Assessment Unit and uses mobility as a vital sign to clarify the patient s health trajectory for discharge planning. The PATH process has been working with the cardiology service to assess frailty burden before planning surgical interventions. Public Education The Division has organized and attended an interactive and educational booth at the Senior s Expo annually for over 1 years on topics of interest and importance to seniors. Additionally, the Division organized Delirium Awareness Month in June 212. This initiative included the launch of the website which includes a short Public Service Announcement (PSA), the presentation of a series of 4 delirium lectures at Geriatric Rounds, public lectures on delirium and an educational booth on delirium at the 5+ Expo. Issues of Appropriateness of Care The PATH program aims to help patients and their families consider the significance of frailty when making medical and surgical decisions; this program is expanding at the QEII HSC and within Canada. Emergency and MTU Coverage Geriatricians provide 12 hour, 7-day emergency and consultative coverage. As well, division members provided 1 weeks of MTU attending coverage, 13 weeks of senior internist physician coverage and 49 shifts of physician on-call coverage to the Emergency Department. DIVISION OF GERIATRIC MEDICINE Dr. K. Rockwood uses Comprehensive Geriatric Assessment in the Emergency Department to help determine which patients need admission and which can be discharged home. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE 77

84 DIVISION OF GERIATRIC MEDICINE Inpatient Services Table 1 Unit/Designation Geriatric Assessment Unit - GAU 15 Progressive Care Unit - PCU 1 Restorative Care Unit - RCU 26 Total 51 # Beds There are 51 inpatient beds designated for Geriatric Medicine. The Progressive Care and Restorative Care Units are co-managed with Family Physicians. Figure 2 Progressive Care Unit Average Bed Utilization by Fiscal Year 12 Beds Used Avail Occupancy Rate Figure 4 Geriatric Assessment Unit Inpatient Bed Occupancy Rate by Fiscal Year 12% Percent Occupancy 1% 8% 6% 4% 2% 112.% 16.2% 113.4% 118.2% 19.% Bed Utilization Figure 1 Geriatric Assessment Unit Average Bed Utilization by Fiscal Year 2 15 The Progressive Care Unit (PCU) has used, on average, 2 less beds than the beds available. Figure 3 Restorative Care Unit Average Bed Utilization by Fiscal Year 3 % The occupancy rate for the GAU in 212/13 decreased to 19.% from 118.2% in 211/12. The number of admissions to this unit increased to 181 in 212/13 from 176 in 211/12. The average length of stay (ALOS) was 28.4 days in 212/13. Beds 1 25 Beds Used Avail The Geriatric Assessment Unit (GAU) has used, on average, 1.3 more beds than the beds available Used Avail This unit is using, on average, 1.1 less beds than the beds available. 78 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE

85 Figure 5 Progressive Care Unit Inpatient Bed Occupancy Rate by Fiscal Year 12% Percent Occupancy 1% 8% 6% 4% 11.8% 115.2% 1.9% 1.1% 8.4% Admissions and Transfers Figure 7 Geriatric Assessment Unit Inpatient Admissions by Fiscal Year 2 Admissions Figure 9 Restorative Care Unit Inpatient Admissions and Transfers In by Fiscal Year 4 Admissions and Transfers DIVISION OF GERIATRIC MEDICINE 2% % Admissions Tranfers In The occupancy rate for the PCU for the fiscal year 212/13 was 8.4% which is a decrease from 1.1% in 211/12. There was a slight decrease in the total number of admissions and transfers in from 125 in 211/12 to 124 in 212/13. Figure 6 Restorative Care Unit Inpatient Bed Occupancy Rate by Fiscal Year 1% Percent Occupancy 9% 8% 7% 6% 5% 4% 3% 89.7% 94.7% 94.7% 92.9% 95.9% Figure 8 Progressive Care Unit Inpatient Admissions and Transfers In by Fiscal Year 16 Admissions and Transfers Admissions Tranfers In % 1% % The occupancy rate for the Restorative Care Unit for 212/13 was 95.9% which is an increase from 211/12 at 92.9%. The total number of admissions and transfers decreased in 212/13 from 329 to 32. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE 79

86 DIVISION OF GERIATRIC MEDICINE Length of Stay Length of Stay includes the patient s entire length of stay in the hospital. The calculation would encompass the first day of admission to hospital, perhaps in ICU, and would end with the patient s discharge from the GAU (Figure 1). The ALOS metric has been revised to include the patient s entire length of stay. Figure 1 Geriatric Assessment Unit Inpatient Average Length of Stay (Days) by Fiscal Year 4 Days The Geriatric Assessor manually captures data to include only the length of stay on the Progressive Care Unit and the Restorative Care Unit. This information is not collected for the Geriatric Assessment Unit. The LOS is 16.3 for PCU and 25.1 for GRC for non ALC patients. Figure 11 Progressive Care Unit Length of Stay Average # Days ALC Patients Non ALC Patients % ALC Patients 9.1% 5.2% 4.1% 5.6% 3.% ** Does not include LOS on other units prior to transfer to PCU Excluded: patients still admitted. Source: Geriatric Assessor The length of stay for those awaiting long term care placement is significantly higher that the LOS for those returning home. Figure 12 Alternative Level of Care The graph below provides alternate level of care (ALC) data for the GAU, PCU, and RCU. The main reason for ALC days is related to a wait for long-term care beds. Patients can also wait in hospital as the home is prepared for their return. Often it takes some time to arrange for support in the home. The data for the wait for long-term/transitional care has been obtained from the Social Work database. The start date begins when the patient is accepted to long-term care and the form is received by Social Work, therefore the actual alternate level of care days might be underestimated. Figure 13 Alternate Level of Care Geriatric Assessment Unit ,5 # ALC Bed Days 2, 1,5 1, Bed Days Available 4,553 4,744 4,77 4,781 5,421 % ALC Bed Days Used 33% 26% 19% 3% 41% # Patients # Expired ALC Bed Days 1,496 1, ,446 2,197 Restorative Care Unit Length of Stay Source: Social Work/Manual In 212/13, 41% of the available bed days were occupied by ALC patients. Average # Days ALC Patients Non ALC Patients % ALC Patients 5.6% 5.2% 8.% 7.3% 2.4% ** Does not include LOS on other units prior to transfer to RCU Source: Geriatric Assessor Excluded: patients still admitted. 8 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE

87 Figure 14 Alternate Level of Care Progressive Care Unit # ALC Bed Days Bed Days Available 3,239 2,978 2,896 2,954 3,669 % ALC Bed Days Used 9% 11% 1% 3% % # Patients # Expired 1 1 ALC Bed Days Source: Social Work/Manual In 212/13, none of the available bed days were occupied by ALC patients. Figure 15 Alternate Level of Care Restorative Care Unit ,6 1,4 Outcome Measures The Geriatric Assessor receives monthly updates from the Discharge Abstract Database (DAD) through Decision Support. Figures have been prepared using this data. Elderly Mobility Scale Figure 16 EMS Scores for Discharged Patients Restorative Care Unit April March Score Avg Admission Score Avg Discharge Score Avg Improvement StDev Improvement Patients Scored Patients Discharged % Patients Scored 88% 81% 5% 72% 82% 8% 74% 83% Target Discharge Score Source: Discharge Abstract Database Goal Attainment Scale A score of means that the patient was able to meet the goals set on admission to the unit. A negative score is worse than expected while a positive score is better than expected. Figure 17 GAS Scores for Discharged Patients Restorative Care Unit April March Score Avg Admission Score Avg Discharge Score Avg Improvement Patients Scored Patients Discharged % Patients Scored 75% 69% 61% 43% 75% 71% 62% 66% Source: Discharge Abstract Database DIVISION OF GERIATRIC MEDICINE # ALC Bed Days 1,2 1, The Elderly Mobility Score was documented upon admission and discharge for most patients in the Restorative Care Unit Bed Days Available 9,262 9,438 9,345 9,15 8,965 % ALC Bed Days Used 3% 6% 9% 15% 8% # Patients # Expired ALC Bed Days , Source: Social Work/Manual In 212/13, 8% of the available bed days were occupied by ALC patients. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE 81

88 DIVISION OF GERIATRIC MEDICINE Barthel Index This self care index measures the patient s ability to perform activities of daily living upon admission and discharge. Figure 18 Barthel Scores for Discharged Patients Restorative Care Unit April March Slight Moderate Severe Complete -2 Score / Dependence Avg Admission Score Avg Discharge Score Avg Improvement Patients Scored Patients Discharged % Patients Scored 89% 88% 85% 74% 82% 78% 7% 81% Source: Discharge Abstract Database Mini Mental Status Exam Figure 19 MMSE Scores for Discharged Patients Restorative Care Unit April March Admission Score Avg Admission Score StDev Score Patients Scored Patients Discharged % Patients Scored 88% 79% 81% 79% 76% 76% 72% 78% Source: Discharge Abstract Database MMSE was documented upon admission for about 75% of patients discharged from RCU. Inpatient Consultations Figure 2 Geriatric Medicine Inpatient Consults Capital Health, ,4 # Consults 1,2 1, Path PCU/RCU Geriatric Medicine Total 1,68 1,148 1,127 1,229 1,328 Source: Geriatric Assessor 1,328 patients were seen in consultation during the fiscal year 212/13. Barthel scores were documented in many of the patients admitted and discharged from the Restorative Care Unit. Figure 21 General Geriatric Medicine Consults by Service Capital Health, # Consults N Card CHU CV DGH Med Nlgy Ortho Other Psych Surg Vasc VMB Total Surg Service % of Total 11% 12% 1% 28% 19% 1% 2% 13% 7% 1% 3% 2% 1% 1% Source: Geriatric Assessor 82 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE

89 Figure 22 Progressive Care Unit Consults by Service Capital Health, # Consults N Card CHU CV DGH ER GAU Home Med Nlgy Ortho Other Surg Vasc Total Surg Service % of Total 7% 11% 5% 8% % 1% 1% 18% 1% 1% 2% 12% 26% 4% 1% Figure 24 PATH Consults by Service Capital Health, # Consults Card CHU CV DGH Med N Surg Nlgy Ortho Other Surg Vasc Total Service % of Total 42% 3% 1% 2% 13% 2% 3% 13% 4% 9% 8% 1% Figure 26 Restorative Care Unit Discharge Sites # Discharges Acute Care Expired Home Home Hospital Nursing Home Total Discharges % Location 3.7% 2.4% 9.9%.3% 2.7% 1.% DIVISION OF GERIATRIC MEDICINE Source: Geriatric Assessor Source: Geriatric Assessor Source: Geriatric Assessor Figure 23 Figure 25 The majority of patients were discharged home from PCU (87.2%) and the RCU (9.9%). At this time data is not collected for the destination of patients discharged from the Geriatric Assessment Unit. Restorative Care Unit Consults by Service Capital Health, Progressive Care Unit Discharge Sites # Consults 2 15 # Discharges Card CHU CV DGH GAU Home Med N Surg Nlgy Ortho Other Surg Vasc Total Service % of Total 2% 4% 4% 17% % 1% 3% 3% 5% 56% 2% 1% 2% 1% Source: Geriatric Assessor Acute Care Expired Home Home Hospital Nursing Home Total Discharges % Location 7.3% 2.4% 87.2%.6% 2.4% 1.% Source: Geriatric Assessor DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE 83

90 DIVISION OF GERIATRIC MEDICINE Inpatient Services Wait Times Figure 27 Wait Time From Referral to Admission Restorative Care Unit 8 # Days Ambulatory Care Figure 29 There were an additional 13 chart checks performed in 212/13 not included in the following figures. Geriatric Medicine Ambulatory Care Registrations 7, 6, Figure 31 Geriatric Day Hospital Program New and Return Ambulatory Care Registrations 3,5 Registrations 3, 2,5 2, 1, Average Wait From Referral Average Wait From Ready Source: Geriatric Assessor Figure 28 Registrations 5, 4, 3, 2, 1, Home Visits Day Hospital 2,819 2,823 3,27 3,172 2,877 Geriatric Clinic 1,873 1,97 1,966 2,56 2,17 Total 5,177 5,285 5,614 5,75 5,389 1, New Return 2,514 2,59 2,667 2,844 2,548 Total 2,819 2,823 3,27 3,172 2,877 % New 1.8% 11.1% 11.9% 1.3% 11.4% There were 2,877 visits to the Day hospital. This number includes visits to the Falls Program. Wait Time From Referral to Admission Progressive Care Unit 8 There were 5,389 registrations to ambulatory geriatric services. This is a decrease of 6.3% from the previous year. Figure 32 6 Figure 3 Geriatric Home Visits New and Return Ambulatory Care Registrations 7 # Days 4 2 Geriatric Ambulatory Clinic New and Return Ambulatory Care Registrations 2,5 2, Registrations Average Wait From Referral Average Wait From Ready Source: Geriatric Assessor Registrations 1,5 1, Code Missing New ,54 Return 974 1, ,69 1,71 Total 1,873 1,97 1,966 2,56 2,17 % New 45.9% 48.6% 47.7% 46.5% 48.6% New Return Total % New 4.2% 47.2% 45.7% 46.2% 39.8% 84 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE

91 Ambulatory Care Wait Times The wait time for urgent consults has remained well below the recommended standard of fourteen days. Figure 33 Geriatric Medicine New Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) 15 Figure 35 Geriatric Day Hospital New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) 6 Days Patient Residency The distribution of patient residency is in the graphs below. The majority of inpatients on the GAU (92.7%) are from the CDHA and (84.9%) of ambulatory patients are from the CDHA. Figure 36 Geriatric Assessment Unit Inpatient Admissions Distribution of Patient Residency by Health District QEII Health Sciences Centre, DIVISION OF GERIATRIC MEDICINE 1 1 Days Average Wait Time Standard Wait Time Count Minimum Wait 1 Maximum Wait % Within Standard 92% 82% 88% 94% 97% Source: PHS Data Figure 34 5 Geriatric Medicine New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) Average Wait Time Standard Wait Time Count Minimum Wait 2 Maximum Wait % Within Standard 91% 31% 5% 75% 57% Source: PHS Data In 212/13, 149 patients were seen in satellite clinics in Antigonish, Lunenburg and Middleton. Satellite visits provide an opportunity to see elderly patients closer to their homes and also provide an excellent teaching opportunity for community physicians. There were 11 TeleHealth visits in 212/13. Other: 1 NB, NF, PEI: 1 SSH: 2 CEHHA: 4 CBDHA: 1 AVDHA: 4 Figure 37 Geriatric Ambulatory Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, CDHA: Days Average Wait Time Standard Wait Time Count Minimum Wait 1 Maximum Wait % Within Standard 41% 25% 37% 37% 32% Source: PHS Data Other: 1 NB, NF, PEI: 24 SWH: 17 SSH: 122 PCHA: 18 GASHA: 1 CHA: 15 CEHHA: 58 CBDHA: 13 AVDHA: 49 CDHA: 1,843 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE 85

92 DIVISION OF GERIATRIC MEDICINE Figure 38 Geriatric Medicine Average Wait Time - Consult Request to Admit Ordered Capital Health, Average Wait Time - Consult Request to Admit Ordered (hrs) Source: EDIS Benchmark Volume Volume *23-8 and 8-23 are based on consult request times. *Times included when the consulting service is also the admitting service Education Dr. K. Koller is the new clerkship educational coordinator/ director of clerkship for Med III and is working with Dr. C. Clarkson to revise the clerkship curriculum for the new Med III internal medicine based rotation. Undergraduate Medical Education 3 Full-Year Med I Electives and 25 Clinical Clerks rotated through Geriatric services. An additional 19 Clinical Clerks rotated through the 3 week Care of the Elderly rotation. Division members provided 98 hours of tutoring in the Case Based Learning program for Med I & II students. Postgraduate Medical Education Geriatricians presented 6 hours of lectures to Academic half day in 212/13 and provided 1 hours as examiners for Internal Medicine resident OSCEs. Geriatricians also contributed 5 hours to CaRMS file reviews and 8 hours to CaRMS interviews. 42 residents rotated through Geriatric Medicine services during the 211/12 academic year including external residents from: Family Medicine Dermatology Division members provided 8 hours of lectures to Med 1 Rotating Electives and 4 hours of lectures to the Med III Wednesday Seminars. They contributed 19.5 hours as examiners for the Med II OSCEs and 23 hours as examiners for the Med III OSCEs. Psychiatry The Royal College requires that all Psychiatry residents undergo psychogeriatric training, which the Division helps to provide. The Division is also involved in postgraduate M.Sc. / Ph.D. training. Continuing Medical Education Geriatricians are active in the provision of continuing medical education, with 5 presentations to general practitioners, specialists, Geriatricians and other health professionals in 212/ DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE

93 Research The Division generated $838,4 in research grants and $77,56 in industry contracts during 211/12 for a total of $915,456. Our researchers are highly productive on a local, national and international stage. There were 26 peer-reviewed publications in the 212 calendar year. Additionally, there were 24 abstracts and/or research presentations at National/International meetings. Dr. K. Rockwood receives external salary support as the Kathryn Allen Weldon Chair in Alzheimer Research. Since September 212, he has authored or co-authored over 25 peer-reviewed articles, including publications in high impact journals such as the Lancet and the Journal of the American Geriatrics Society. These papers continue on the themes of frailty and of clinical and population aspects of the dementias and their treatment. He authored a chapter on The concept of frailty in the Oxford Desk Reference: Geriatric Medicine, and was a co-contributor for chapters in three additional text books. Many invited, named lectures were given, including international presentations in China, the UK, as well as in the United States and across Canada. In the past year he has received several awards, including the Canadian Geriatrics Society s Ronald Cape Distinguished Service Award and the Queen Elizabeth II Diamond Jubilee Medal for dedication to the care of older patients and research leadership in the field of gerontology. Dr. Rockwood chairs the Canadian Dementia Knowledge Translation Network and the Canada China Collaboration on Aging and Longevity, which are funded by the Canadian Institutes of Health Research (CIHR). He also holds peer-reviewed support from Capital Health, the Complex Systems Canadian Research Network, the National Natural Sciences Foundation of China, CIHR and is a member of several national and provincial research committees. He is a member of the Medical Advisory Board of Alzheimer Disease International. He has been formally appointed as a mentor for two junior staff members of Dalhousie faculty. He continues to be active in peer review, and reviewed papers for prestigious journals such as the Lancet and JAMA. He is on the editorial board of half a dozen journals including BMC Medicine. He supervises four post-doctoral fellows, who receive funding from the Alzheimer Society of Canada, the CIHR, a Killam Award, and a University Internal Medical Research Foundation award. Dr. Rockwood is a recognized leader nationally and internationally in the fields of geriatric medicine, frailty and Alzheimer research. The Divisional collaboration with the Canadian Centre for Vaccinology (CCfV) and Dr. S. McNeil from the Division of Infectious Diseases investigates the importance of frailty for vaccine effectiveness and clinical outcomes of influenza infection in older adults. The focus on frailty is a unique aspect of this work, and is attracting international interest, for example from the World Health Organization (WHO). Administration Geriatricians perform the following administrative activities: Division Head and Director for the Centre for Health Care of the Elderly, including all responsibilities of the position. Executive/Divisional Chief Committee Director of the Geriatric Medicine Research Unit Director of the Centre of Health Care for the Elderly Program Director for Geriatric Medicine Residency Training Program Service Chief duties for these areas: Geriatric Ambulatory Care Geriatric Assessment Unit Geriatric Day Hospital Geriatric Restorative Care Unit Progressive Care Unit Consultations & Community Outreach Chair duties for these areas: CHCE Advisory Quality & Patient Safety Committee CHCE Management Committee Council of Reference Geriatric Academic Rounds Committee DIVISION OF GERIATRIC MEDICINE Morbidity & Mortality Committee Co-Founder/Co-Chair, PATH Clinic Department of Medicine Appropriateness of Care Working Group DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE 87

94 DIVISION OF GERIATRIC MEDICINE Co-Chair, Capital Health Research Ethics Committee Chair, Canadian Dementia Knowledge Translation Network Chair, Nova Scotia Department of Health Formulary Management Committee Chair, Protocol Review and Study Selection Committee, Consortium of Canadian Centres for Clinical Cognitive Research Chair, Research Awareness Breakfast, Alzheimer Society of Nova Scotia Chair, Research Advisory Board, Alzheimer Society of Nova Scotia Division members provide referee or editorial services to 34 journals/granting agencies in 212/ DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF GERIATRIC MEDICINE

95 Division of Hematology DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY 89

96 DIVISION OF HEMATOLOGY Physician Resources 1 Hematologists (7.45 FTE) 7 full-time 3 part-time Dr. Hayne re-joined the Division of Hematology on a parttime basis in October 212. Dr. Hasegawa reduced her work to part-time effective October 212. Divisional Highlights Dr. Couban was named Division Head/Service Chief and began a 5-year term in 212/13. Dr. Shivakumar was awarded the Professor of the Year Award in October 212. Dr. Shivakumar was also nominated as a QEII Foundation Angel in Action by a grateful patient, family or peer in September 212. Dr. Robinson was nominated as a QEII Foundation Angel in Action by a grateful patient, family or peer in 213. Drs. Shivakumar, Couban and Ms. Joanna Slusar were the recipients of a Capital Health Quality of Care Bronze Medal Award in April 213 for the session entitled: Patient-Specific Responses to Request for Consultation: A Hematology Ambulatory Care Quality Initiative. New Programs, Partnerships and Innovations In partnership with Capital Health, the Division of Hematology is developing an Inpatient Nurse Practitioner role for the General Hematology Inpatient Service. The Division has also redesigned the Inpatient Consultation service to provide additional capacity to see urgent new outpatient referrals in a timely manner. Dr. Couban continues to prepare letters to referring physicians providing advice and recommendations for certain categories of referrals. Service to the Sydney satellite clinic continued until June 3, 213. Service to the Moncton and St Johns satellite clinic continue. After a successful term as Core Internal Medicine Residency Program Director, Dr. White completed his term in February 213. The Division hosted 1 distinguished speakers in 212/13 for Hematology Grand Rounds. 9 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY

97 Work for the Nova Scotia Department of Health and Wellness Dr. Anderson continues to serve as a clinical advisor for the Nova Scotia Blood Coordinating Program and is a member of the National Advisory Committee on blood and blood products. The Nova Scotia Blood Coordinating Program provides support for improving the appropriateness of utilization of blood products and the implementation of improved laboratory practice as well as enhancing surveillance for adverse transfusion reactions. Major programs in the past year have included an intravenous immunoglobulin (IVIG) utilization project, implementation of steps to reduce red cell wastage, the development of a provincial contingency plan for blood shortages and massive transfusion as well as standardization of reporting of adverse transfusion events. Quality Patient Safety Dr. Wanda Hasegawa is the medical lead of a process at Capital Health for the Blood and Marrow Transplant Program to achieve Foundation for Accreditation of Cellular Therapy (FACT) accreditation. This is an international standard which all transplantation centers will be required to achieve in order to continue to perform transplantation procedures. She has also been the medical lead to prepare for accreditation by Health Canada. Average Length of Stay The Division continues to undertake certain types of autologous and allogeneic Blood and Marrow Transplant on an outpatient basis. In addition, Day 1 transfer of recipients of autologous transplant to Moncton General Hospital continues and efforts to replicate this process for patients returning to the George Dumont Hospital in Moncton, NB have also started as well. Division members continue to work with colleagues in nursing, pharmacy and social work to expedite discharges and facilitate appropriate transfers and discharges. Public Education Members of the Division participate in public education endeavors including participating in the advisory boards of patient advocacy groups including the Aplastic Anemia Myelodysplasia Society (Dr. Couban) and Myeloma Canada (Dr. White). Clinical Services Division members provide secondary, tertiary and quaternary care for patients with benign and malignant hematological disorders. This includes the administration of chemotherapy and stem cell transplantation procedures for patients with leukemia, lymphoma and multiple myeloma, along with diagnostic and therapeutic services for patients with thromboembolic and major bleeding disorders. The Division runs an inpatient service at the Victoria General site as well as delivering outpatient care through the Hematology Clinic and Medical Day Unit and through satellite clinics in Moncton, Sydney, St. John s and the IWK Health Centre. DIVISION OF HEMATOLOGY Emergency Coverage Hematologists provided 24-hour, 7-day / week emergency and on-call inpatient consultation service for the QEII Health Sciences Centre (QEII HSC). Hematologists provided advice and urgent consultation services to physicians in the Maritime Provinces. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY 91

98 DIVISION OF HEMATOLOGY Inpatient Services (General Hematology and BMT) There are 2 inpatient beds designated to the General Hematology Service and the Blood and Marrow Transplant (BMT) Service. Table 1 Figure 2 Hematology Average Bed Utilization by Fiscal Year 2 Figure 4 Hematology Inpatient Average Length of Stay (Days) by Fiscal Year Unit/Designation 8A/8B General Hematology & BMT 2 Beds Beds 15 1 Days Current and historical occupancy rates and bed utilization on Hematology and BMT Nursing Units have been merged to more fully reflect the Hematology Inpatient services in this report. The average occupancy rate (according to midnight census) for 212/13 was 1.5%. The bed utilization shows an average of 18.7 beds used, with 18.6 available. Figure 1 Hematology Inpatient Bed Average Occupancy Rate by Fiscal Year 12% Total Used Available patients were admitted to the Hematology Inpatient Services during 212/13, representing an 8.3% increase from the previous year. Additionally, 25 patients were transferred to Hematology care from other parts of the QEII HSC for a total of 716 admissions and transfers for the year. Average Length of Stay (ALOS) was 13.1 days Of the Hematology inpatient admissions in 212/13, 59% were male and 41% were female. 42.1% of admissions came from Nova Scotia Health Districts outside of Capital while an additional 12.7% came from other Atlantic Provinces. These ratios are reflective of the tertiary and quaternary nature of the service. 1% 95.9% 94.7% 97.% 1.5% Figure 3 Figure 5 Percent Occupancy 8% 6% 86.5% Hematology Inpatient Admissions and Transfers In by Fiscal Year 8 Hematology Inpatient Admissions Percent Distribution by Gender QEII Health Sciences Centre, % 7 2% % Admissions and Transfers Female: 41% 2 1 Male: 59% Tranfers In Admits Total DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY

99 Figure 6 Hematology Inpatient Admissions Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, Out of Province: 65 Capital District: 231 Blood and Marrow Transplant Program (BMT) The Blood and Marrow Transplant program has served patients throughout the Maritimes since There were 98 blood and marrow transplants completed in 212/13, an increase of 1.% from the previous year. Figure 8 Inpatient Consultations The graph below depicts a combination of activity on the Hematology Inpatient Consult service and service to the Medical Teaching Unit (MTU) and Internist Emergency Department Call Rotation by division members over the past 5 years. There were 987 inpatient consults at the QEII Health Sciences Centre reported for Hematologists in 212/13, representing a 1.2% increase from the previous year. DIVISION OF HEMATOLOGY Non Capital District: 215 Blood and Marrow Transplant 12 Figure Hematology Inpatient Consults 1,2 Figure 7 Hematology Inpatient Admissions Distribution of Patient Residency by Atlantic Province QEII Health Sciences Centre, Newfoundland: 8 Prince Edward Island: 19 Transplants Syngenic Transplant Related Non-Myeloablative Matched Unrelated Myeloablative Related Allogenic Myeloablative Autologous Total Source: Data Administrator, Oncology Services Consults 1, , New Brunswick: Source: Physician Services Nova Scotia: 446 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY 93

100 DIVISION OF HEMATOLOGY Ambulatory Care There were 1,795 patient registrations to the six subspecialty outpatient services during 212/13, which represents a 1.8% decrease relative to the previous year. Of the 212/13 clinic visits, 18.7% were new consults. Patients undergoing chemotherapy require many return visits. Data includes visits to non-physicians such as nursing and pharmacy. There were an additional 2,767 chart checks performed in 212/13 not reported in the following figures. Figure 11 Hematology New and Return Ambulatory Care Registrations QEII Health Sciences Centre & Cobequid Community Health Centre , Registrations 12, 1, 8, 6, Special Service Commitments 153 patients were seen in the Moncton BMT Clinic during 212/13;.7% of these visits were new patients. Figure 12 Hematology Clinic Visits Moncton Clinics, Figure 1 Hematology Ambulatory Care Registrations QEII Health Sciences Centre & Cobequid Community Health Centre , Registrations 1, 8, 6, 4, 4, 2, New 2,794 2,238 2,89 2,57 2,14 Return 8,56 7,992 8,555 9,539 8,781 Total 11,3 1,23 11,445 12,19 1,795 % New 24.7% 21.9% 25.3% 21.2% 18.7% Visits New Return Total % New 3.3% 1.6% 5.%.6%.7% Source: Divisional Data 2, Autologous B Hereditary Bleeding Disease Blood & Marrow Transplant Deep Vein Thrombosis 944 1, ,137 1,144 Hematology 3,14 2,647 3,347 2,588 2,64 Oncology 5,485 5,87 5,265 5,954 6,52 Total 1,65 9,639 1,683 1,966 1, patients were seen in the Newfoundland and Labrador BMT Clinic during 212/13; 12.2% of these visits were new patients. Figure 13 Hematology Clinic Visits St. John's, Newfoundland Visits New Return Total % New 19.4% 11.1% 7.6% 18.1% 12.2% Source: Divisional Data 94 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY

101 86 patients were seen in the Sydney Clinic during 212/13. Figure 14 Hematology Clinic Visits Sydney Clinics, February 211- March Visits New Return Total % New 45.5% 3.7% 41.9% Source: Divisional Data 42 patients were seen in the High-Risk Pregnancy Clinic for Women with Hematological Disorders at the IWK Health Centre in 212/13. Figure 15 Hematology Clinic Visits IWK PNC Hematology Clinics, Visits Wait Times and Outpatient Throughput All patients referred to the Division of Hematology are triaged centrally by a Hematologist. Urgency is assigned using criteria in the table below. During the 4th quarter of 212/13, average wait times were within standard for all triages. It should be noted that effective October 29 the division began a pilot providing written advice to referring physicians in place of a clinic visit for certain less-urgent referrals. Guidelines for Triage of New Referrals to Hematology Outpatient Clinics Emergent (C1) Examples include: New diagnosis of acute Leukemia Severe thrombocytopenia Severe Anemia Severe Leukopenia Urgent (C2) Examples include: New diagnosis of Lymphoma/Hodgkin s disease Semi-urgent (C3) Examples include: New Diagnosis of Myeloma Moderate Anemia, Moderate Thrombocytopenia New diagnosis of chronic myeloid leukemia (stable) Non-urgent (C4) Examples include: Homozygous HFE C282Y Hemachromatosis Mild cytopenias Duration of anticoagulation New diagnosis of chronic lymphocytic leukemia (stable) Personal or Family History of previous thrombosis Standard Wait Time Within 48 hours Within 2 weeks (14 days) Within 6 weeks (42 days) Within 13 weeks (9 days) DIVISION OF HEMATOLOGY New Return % New 44.7% 61.4% 53.% 6.% 71.4% Total Source: Meditech DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY 95

102 DIVISION OF HEMATOLOGY Figure 16 Hematology Emergent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days 2 1 Figure 18 Hematology New Semi-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Of the outpatient clinic registrations in 212/13, 39.% reside in Nova Scotia Health Districts outside of Capital while an additional 7.3% came from outside Nova Scotia. Figure 2 Hematology Clinic Registrations Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, Out of Province: 991 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 96% 98% 93% 92% 95% 94% 92% 94% Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 82% 84% 85% 73% 83% 74% 82% 8% Source: PHS Data Source: PHS Data Non Capital District: 5,316 Capital District: 7,38 Figure 17 Figure 19 Hematology New Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Hematology New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Days Average Wait Time Standard Wait Time Count Minimum Wait 1 2 Maximum Wait % Within Standard 81% 72% 8% 72% 68% 88% 69% 73% Source: PHS Data Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 59% 74% 53% 7% 6% 61% 71% 81% Source: PHS Data 96 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY

103 Medical Day Unit (MDU) Most ambulatory Hematology care at the QEII HSC occurred in the Medical Day Unit. This activity accounted for 69.8% of the activity of the MDU during the year. The proportion of activity has been relatively constant over the last five years. There were 16,665 patients registered in five subspecialty programs in the Medical Day Unit in 212/13, representing a 5.7% increase in total activity from the previous year. Figure 21 Hematology Medical Day Unit Proportion of Total Medical Day Unit Registrations 18, Visits 16, 14, 12, 1, 8, Figure 23 Hematology Medical Day Unit Registrations Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, Non Capital District: 2,94 Out of Province: 1,39 DIVISION OF HEMATOLOGY 6, 4, 2, Total Medical Day Unit 12,517 13,68 14,518 15,761 16,665 Total Hematology 9,15 9,388 1,124 1,65 11,634 Percent Hematology 72.% 71.8% 69.7% 67.6% 69.8% Capital District: 7,691 Figure 22 Figure 24 Hematology Medical Day Unit Ambulatory Care Registrations 14, Hematology Average Wait Time - Consult Request to Admit Ordered Capital Health, April 28 - March Registrations 12, 1, 8, 6, 4, 2, MDU Autologous 1 1 MDU Apheresis Bone Marrow MDU Bone Marrow MDU Apheresis Hematology MDU Hematology 8,363 9,6 9,96 1,431 11,557 Total 9,15 9,388 1,124 1,65 11,634 Average Wait Time - Consult Request to Admit Ordered (hrs) Benchmark Volume Volume Source: EDIS *23-8 and 8-23 are based on consult request times. *Times included when the consulting service is also the admitting service DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY 97

104 DIVISION OF HEMATOLOGY Education All hematologists were involved in the provision of medical education during the year. Hematologists provided 6 weeks of attending service on the MTU, 35 shifts as Internist on-call to the Emergency Department during the 212/13 academic year. Postgraduate Medical Education 52 residents rotated through the Hematology service during the 212/13 academic year, including 17 externals from the Pathology, Nuclear Medicine, Family Medicine, Hematologic Pathology, Anaesthesia, Radiation Oncology and Neurology. Continuing Medical Education Hematologists were active in the provision of continuing medical education, with 35 sessions presented to general practitioners, specialists and other trainees in 212/13. Undergraduate Medical Education Hematologists contributed directly to undergraduate education by tutoring, lecturing, clinical demonstrations, evaluation, electives and course development. The Undergraduate Education Program for the Division of Hematology is led by Dr. Sudeep Shivakumar. Dr. Shivakumar continues to play a lead role in the redesign of the medical school curriculum, and has served as Hematology Component Head for Host Defense Unit since November Med 1-4 students, including electives, did rotations through the division in the 212/13 academic year. Division members delivered 8 hours of Med I Rotating Electives, 48 hours as tutors for Med I and II Case-Based Learning (CBL), 48 hours of Med II Clinical Skills, 8 hours of Med III Clerkship Seminars and 24 hours as examiners for Med II and Med III OSCE in the 212/13 academic year. Division members delivered 9 hours of Academic Half Day teaching, 8 hours of CaRMS File Review, 72 hours of CaRMS interviews, and 1 hours as examiners for Resident OSCE in the 212/13 academic year. Sub-specialty Medical Education The Division of Hematology offers a two-year Hematology residency-training program, fully accredited by the Royal College of Physicians & Surgeons of Canada. The Postgraduate Education Program for the Division of Hematology continues to develop under the direction of Dr. Kew. Dr. Kew has undertaken a major transformation of the program with a transition to case-based learning in the Academic Half-Day. In 212/13, she led the successful accreditation of the post-graduate training program by the Royal College. Dr. McCurdy completed her Fellowship in October 212, and accepted a position at the Mayo Clinic in Rochester, MN. Dr. Costello completed her Hematology Fellowship Training Program with Dalhousie University in May 213, with the final 6 weeks of training spent in Newfoundland. Drs. Sharif, Pardy and Zed continued in the Hematology Fellowship Training Program in 212/13, and Dr. Gallivan will begin the Program in July DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY

105 Research Division members continue to maintain positions of prominence within the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG). Dr. Couban co-chairs the Hematology Site Group at the NCIC CTG. Dr. White is a member of the NCIC CTG Myeloma Committee, Dr. Macdonald is a member of the NCIC CTG Lymphoma Committee and the NCIC CTG Audit and Monitoring Committee and Dr. Hasegawa is a member of the NCIC CTG Audit and Monitoring Committee. Dr. Anderson serves as Assistant Dean of Clinical Research for the Dalhousie Faculty of Medicine. Administration Hematologists performed the following administrative activities: Division Head, including all responsibilities of the position. Dr. Anderson serves as clinical advisor to the Nova Scotia Blood Coordinating Program and Chair of the Capital Health Blood Transfusion Committee. Service Chief duties for In-patient Units (8A/8B & BMT) Division member, Dr. Robinson assumed the role of Chair, Promotions & CAPR Review Committee. Division member, Dr. White assumed the role of Chair, Department of Medicine Education Awards Committee. Divisional members assumed a leadership role in administration by participating in department committees, Capital Health/IWK committees and university and other affiliated organization committees. DIVISION OF HEMATOLOGY Members are also leaders in clinical research in thromboembolic and major bleeding disorders There were 2 peer-reviewed papers published by division members in 212/13. 1 abstracts were presented at National/International scientific meetings in 212/13. Division members acted as Medical Directors for: Bone Marrow Transplant Program Hereditary Bleeding Disorders Clinic Thrombosis Anticoagulation Program Medical Day Unit Apheresis Hematology High Risk in Pregnancy Clinic Hematologists provided referee and editorial services for 1 journals/granting agencies during 212/13. The Division generated $2,186,454 in research grants and industry contracts during 212/13. Division member, Dr. White assumed the role of Program Director for Core Internal Medicine Residency Training Program until February 28, 213. Division member, Dr. Kew assumed the role of Program Director for the Residency Training Program. Division member, Dr. MacDonald assumed the role of Chair, Department of Medicine Resident Research Committee. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF HEMATOLOGY 99

106

107 Division of Infectious Diseases DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES 11

108 DIVISION OF INFECTIOUS DISEASES Physician Resources 5 Infectious Diseases Specialists (4.3 FTE) 4 full-time 1 part-time Divisional Highlights There were no substantive changes to the Division s inpatient clinical services delivery in 212/13. Functionally, the Division continues to be divided into two service sites: the Halifax Infirmary, which is heavily weighted towards patients with severe communityacquired infections and nosocomial infections, and the Victoria General where the majority of referrals are patients compromised by hematopoietic stem cell and solid organ transplantation and patients with complicated intraabdominal infections. We see patients with a variety of infectious diseases in our outpatient clinics. A large part of our practice continues to be management of patients on home intravenous antimicrobial therapy for chronic infections. There is no organized outpatient antibiotic therapy program in Nova Scotia and so this work tends to be labour-intensive without the supports that would come from such a program. The Sexually Transmitted Diseases (STD) Clinic has treated an increasing number of patients with syphilis as the result of an outbreak in Capital Health District, primarily among men who have sex with men. Dr. Johnston completed terms as President of the Association of Medical Microbiology and Infectious Disease Canada and Chair of the Royal College Specialty Committee in Infectious Diseases and was elected to a 3-year term as a Board member of Doctors Nova Scotia. Dr. LeBlanc became a Fellow of the Canadian College of Microbiologists in May 212. Dr. McNeil was promoted to Professor of Medicine on July 1, 212. Dr. Slayter received the following awards in 212/13: The Pharmacy Association of Nova Scotia Appreciation of Service Award, Distinguished Alumnus of the Year, College of Pharmacy, Dalhousie University, 213 and Outstanding Researcher of the Year, Canadian Centre for Vaccinology, 213. Dr. Webster received the Dalhousie Medical Alumni Association Young Alumnus of the Year Award and the Asclepian Torch Award for Excellence in Clinical Teaching - Atlantic Health Sciences Centre (AHSC) in 212. In March 213, Dr. Johnston joined a team of surgeons (plastic, orthopedic, and vascular) and a wound care nurse specialist to form the Multidisciplinary Leg Ulcer Clinic (MDLUC), based out of the Halifax Infirmary Vascular Surgery Clinic. An unacknowledged aspect of our patient care contributions are the hundreds of telephone calls we take each year, giving patient management advice to physicians caring for patients throughout the Maritimes. 12 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES

109 New Programs and Initiatives A Multidisciplinary Leg Ulcer Clinic (MDLUC) was started in March 213, based out of the Vascular Surgery Clinic at the Halifax Infirmary. This initiative, spearheaded by Dr. Mark Glazebrook, brings together orthopedic, plastic, and vascular surgeons and infectious diseases physicians in the management of lower leg ulcers of a variety of etiologies. It is supported in its work by a full time clinical nurse specialist in wound care and a Pedorthist. Each of the specialties sees patients on a different half-day, with the patients booked to see the specialist most pertinent to their active problems. The wound specialist nurse attends all the clinics, crucial to maintaining continuity. At a minimum, this set- up minimizes the number of different clinics the patient with a leg ulcer has to attend for care. A number of factors contribute to the development of non-healing leg ulcers, including vascular insufficiency, structural deformities, impaired wound healing, and infection. Non-healing leg ulcers are associated with significant morbidity, mortality, and medical and personal costs. The objective of a multidisciplinary approach is to improve patient outcomes in all domains. The MDLUC initiative will be evaluated as part of the Master s thesis of Dr. Tina Lafrancois, an orthopedic surgery resident. The Medical Director, Health Services Manager, and Nurse for the STD clinic have been working closely with Nova Scotia Public Health to more efficiently do contact tracing for STD Clinic patients. In the past, much of the follow up was done by the STD clinic nurse, which eroded into time meant for STD clinic itself and contributed to very long clinic hours. For several months, a Public Health nurse has been attending clinics at the Dickson Building and working side by side with the STD clinic nurse to optimize contact tracing. A triage system has also been put into place to identify patients coming for syphilis treatment, so that these patients will not be turned away from this walk-in clinic. It is anticipated that these initiatives will result in fewer patients being turned away from STD clinic and less overtime costs. Dr. Johnston is serving as a Medical Co-Lead for the Capital Health Ambulatory Care Realignment Project at the VG, intended to provide more accessible, efficient, and cost-effective outpatient facilities to outpatients. Work for the Nova Scotia Department of Health and Wellness Dr. Johnston continued as Chair of The Infectious Diseases Expert Group (IDEG) to the Department of Health and Wellness (DoHW). Other Division members on IDEG are Drs. Haldane and McNeil. IDEG provided the DoHW with advice on fecal transplantation, recommending that this should still be considered an experimental procedure and that we would be better served by a comprehensive process for the prevention and proper management of Clostridium difficile infection, rather than focusing on the last resort measure. IDEG recommended that the province adopt an opt-out process for prenatal HIV testing. This is currently under consideration by the Advisory Commission on AIDS as it renews its HIV strategy. IDEG also recommended to the Department that it formalize a provincial antimicrobial stewardship program and increase support to its provincial infection prevention and control program by employing physician resources and stewardship pharmacist. The DoHW is in the process of establishing a working group around C. difficile. No action has been announced on the latter two recommendations (opt-out HIV testing and infection prevention and control and antimicrobial stewardship). Failure to appropriately support antimicrobial stewardship and infection prevention and control is of concern to IDEG, Infectious Diseases physicians and clinical and medical microbiologists in the face of increasing prevalence of antimicrobial resistance and the threat of institutional C. difficile outbreaks. IDEG also recommended immunizations for immunecompromised pediatric and adult patients, which were proposed by Drs. McNeil and Slayter and accepted by government. DIVISION OF INFECTIOUS DISEASES DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES 13

110 DIVISION OF INFECTIOUS DISEASES Drs. McNeil and Hatchette are members of the Nova Scotia Advisory Committee on Human Papillomavirus (HPV) Immunization, which makes recommendations to the DoHW regarding implementation of the HPV Immunization Program and identifying and undertaking research regarding HPV in NS. Dr. Haldane continues to serve as Director, Nova Scotia Public Health Laboratory. All of the ID physicians receive calls and s from the Public Health Nurses and Medical Officers of Health asking for advice on a variety of infectious diseases. Dr. Johnston finalized, in consultation with Drs. Langley, Hatchette, and Sommers, an algorithm on the prevention, diagnosis, and treatment of Lyme disease for Nova Scotia physicians. Dr. Johnston provided detailed feedback on the DoHW s plan for public reporting of institutional hand hygiene adherence rates and C. difficile rates and its best practices guidance for preventing healthcare associated C. difficile infection. Dr. Hatchette s anonymous seroprevalence survey for Lyme disease, Anaplasma, and eastern equine encephalitis virus among Nova Scotians has completed data collection, with data analysis in progress. Dr. Slayter has been part of a provincial initiative to evaluate and consider implementing a provincial antimicrobial stewardship program. Quality and Patient Safety The Division continues to monitor compliance with immunization and infectious disease screening in the HIV population. The goal is to prevent infections in these patients through 1% uptake of primary prevention measures including vaccines and antibiotic prophylaxis. A process has been recently introduced whereby HIV patients community pharmacies are notified of their antiretroviral therapies, where consent to do so is provided. As hospital epidemiologists, Drs. Davis and Johnston work with Capital Health Infection Control to implement and evaluate various strategies to prevent the crosstransmission of infection in Capital Health facilities. Over the last year, the campaign to promote adherence with hand hygiene across the District has continued, with hand hygiene education and observation of hand hygiene adherence an integral part of the activities. Drs. Davis and Johnston are frequently called upon to provide physician leadership to these initiatives. Other key patient safety activities include making staff aware of their role in preventing hospital-acquired infections and ensuring that there are policies, procedures, and practices in place for the appropriate cleaning and disinfection or sterilization of patient care equipment and devices. Focused effort has been on ensuring processes and lines of accountability for reprocessing of endoscopes across Capital Health. Dr. Johnston, as Chair of the Infection Control (IC) Guidelines Steering Committee for the Public Health Agency of Canada (PHAC), is involved in the development of guidelines intended to prevent health care associated infections (HAI). Prevention of HAI is a key patient safety measure. Guidelines on preventing the transmission of the new flu virus (H7N9) and the novel Middle East coronavirus (MERS-CoV) in health care settings were produced and posted, gaining attention for their clarity and practicality by the World Health Organization (WHO). As Chair of the Antimicrobial Agents Subcommittee, Dr. Slayter supervises the introduction of policies and procedures to ensure the safe and appropriate use of antimicrobials throughout Capital Health District. Dr. Slayter produced a business proposal to establish a formal antimicrobial stewardship program at Capital Health. While the proposal did not receive approval for implementation, Dr. Slayter has provided significant content expertise to the Division of Critical Care Medicine as it implements a strategy to improve its use of antimicrobials. Canadian Institute for Health Information (CIHI) data suggested higher than anticipated mortality rates for patients with sepsis admitted to the QEII HSC in 21. Dr. Johnston has participated in a working group to explore this finding. She assisted Dr. Sarah McMullin of the Division of Critical Care Medicine in the development of an audit tool for chart review and will assist in data collection and analysis. The time period in question was before the sepsis preprinted orders and algorithms were rolled out in the Emergency Department and inpatient wards. It is anticipated that findings from this quality review will corroborate the value of these preprinted orders and algorithms as a tool for the better management of sepsis. Dr. Slayter was central to the development and implementation of these sepsis tools, which can be found in the Capital Health antimicrobial handbook. 14 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES

111 Efforts to Eliminate Shadow Charts The division maintains shadow charts for the HIV and Hepatitis C (HCV) population only. For the HIV patients, the information collected is entered into our HIV clinic database and sent to Horizon Patient Folder (HPF). There is minimal maintenance required, as this is essentially a temporary record to facilitate patient visits and telephone follow-up, rather than the primary record of care. For HCV patients, the chart includes handwritten notes of patient visits and a flow chart of lab results. Over the past several years, the Division has made proposals to develop electronic forms for use in these clinics. Despite offering to fund the initiatives, these requests have not received approval at this time. Public Education Each new HIV patient is provided written information, including a book on HIV and self-care provided by CATIE: Canada s Source for HIV and Hepatitis C Information. At clinic visits, risk behaviours (smoking, drinking, street drug use, unsafe sex practices) are reviewed with HIV and HCV clinic patients and strategies for harm reduction or elimination discussed. Referrals to community resources are made as necessary. We have offered our HIV patients a personalized chart that they can use to track their medications, immunizations, and lab results. Very few have taken us up on this offer. STD clinic visits are used as an opportunity to review measures for STD prevention and free condoms are provided. Issues of Appropriateness of Care Division members, through both patient consultation activities and participation on the Antimicrobial Agents Subcommittee, are paramount to the appropriate use of antimicrobials. There are individuals in Nova Scotia who are inappropriately treated for Lyme disease, when they do not have it. The Division s involvement in public and physician education, development of resources on the DoHW website, Dr. Hatchette s serosurvey, and patient consultations are all efforts to ensure the appropriate diagnosis and treatment of Lyme disease in Nova Scotia. DIVISION OF INFECTIOUS DISEASES General ID clinic visits are used as an opportunity to educate patients on preventing recurrent infections, particularly cellulitis, diabetic foot infections, urinary tract infections, and abscesses. Division members have been interviewed by the QEII Foundation magazine on such topics as Lyme disease and adult immunization. The DoHW website for Lyme disease is intended to be a public education tool, as well as a resource for physicians. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES 15

112 DIVISION OF INFECTIOUS DISEASES Clinical Services Specialized infectious diseases care for patients in the Capital District Health Authority and tertiary care for the province includes: Inpatient Consultation Service Telephone Consultation Services (24hrs/day; 7 days per week) General Infectious Diseases Clinic Hepatitis C Clinic HIV Program STD Clinic Emergency Coverage Infectious Diseases (ID) physicians provide 24-hour, 7-day emergency and on-call coverage. Inpatient Services There are no designated Infectious Diseases beds in Capital Health. In 212/13, the ID physicians provided 14 weeks of attending service to the Department of Medicine s Medical Teaching Unit (MTU), 2 weeks as Senior Internist and 21 shifts as Internist On-Call to the QEII HSC Emergency Department. Inpatient Consultations Infectious Diseases Inpatient consultation service is provided at the HI, VG, VMB, Abbie Lane, and NSRC sites of the QEII HSC. On occasion, inpatient consultation service is requested and provided to the Dartmouth General Hospital (DGH) and the IWK Health Center (IWK HC). The table and graph below depict a combination of activity on the ID Inpatient Consult service and service to the MTU and Senior Internist rotations by select division members since 28/9. There were 1,49 new inpatient consults and 5,921 follow-ups performed in 212/13, which represents an overall increase of 12.8% from 211/12. Inpatient activity by division members who are cross-appointed with the Departments of Pathology and Microbiology/ Immunology is included in the figures as well. Table 1 Monthly HIV/Hepatitis Clinic at Burnside Correctional Centre Hospital Epidemiologist / Infection Control Inpatient Consultations by Fiscal Year Year Consult Follow-Up Total ,426 5,14 6, ,521 5,378 6, ,531 5,418 6, ,445 5,125 6, ,49 5,921 7,411 Source: MOM Data Antimicrobial Utilization Multidisciplinary Leg Ulcer Clinic (starting March 213) 16 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES

113 Figure 1 Infectious Diseases Inpatient Consults 8, Consults 7, 6, 5, 4, 3, 2, 1, Total 6,44 6,899 6,949 6,57 7,411 Return 5,14 5,378 5,418 5,125 5,921 New 1,426 1,521 1,531 1,445 1,49 Source: MOM Telephone Consultations The Infectious Diseases physicians provide telephone consultations on a 24/7 basis to other physicians. Division members rotate providing consultation advice on a monthly basis. Calls are taken from Nova Scotia, Prince Edward Island and New Brunswick. There were 1,14 telephone consultations recorded in 212/13, which is a 6.3% decrease from the previous year. This number reflects only those calls that are phoned into the office during regular working hours, and does not include calls that go through locating. Table 2 Ambulatory Care The Division of Infectious Diseases runs four ambulatory care clinics: General Infectious Diseases, Hepatitis C, HIV, and STD (walk-in). There were 4,563 patient registrations to all of the Infectious Disease clinics in 212/13, including 57 visits at Burnside Correctional Centre. The following graph provides an overall summary. There were an additional 647 chart checks performed in 212/13 not reported in the following figures. Figure 2 Infectious Diseases Ambulatory Care Registrations 5, DIVISION OF INFECTIOUS DISEASES Telephone Consultations by Fiscal Year , , , ,14 Source: Manual Data Collection 4,5 4, 3,5 3, 2,5 2, 1,5 1, Hepatitis C HIV Program Infectious Diseases 1,4 1,224 1,418 1,89 1,724 STD 1,276 1,344 1,413 1,668 1,735 Total 3,457 3,629 3,985 4,598 4,563 Registrations General Infectious Diseases Clinic The General Infectious Disease Clinic provides services to patients with a range of potential infections. Examples of patients seen include individuals with positive tuberculin skin tests or a history of TB, recurrent cellulitis, atypical mycobacterial infection, genital herpes, recurrent urinary tract infection, and patients with fever of unknown origin. Outpatient follow-up is provided to many patients who were seen during inpatient consultation (e.g., patients with endocarditis, sternal wound infection, prosthetic joint infection, and osteomyelitis). DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES 17

114 DIVISION OF INFECTIOUS DISEASES There were 1,724 registrations to the General Infectious Diseases Clinic in 212/13, representing a 4.7% decrease from the previous year. Of these clinic visits, 23.8% were new consults. Figure 3 Infectious Diseases Ambulatory Care Registrations 25 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total , , , , ,724 Figure 4 Infectious Diseases New and Return Ambulatory Care Registrations CodeMissing New Return ,238 1,158 Total 1,4 1,224 1,418 1,89 1,724 % New 37.6% 27.9% 25.2% 25.6% 23.8% Registrations Hepatitis C Clinic (HCV) The HCV clinic is interdisciplinary, with patients routinely seen by the physician, nurse, and pharmacist. We provide HCV care to our HIV/HCV co-infected patients. There were 238 registrations to the HCV clinic in 212/13, representing a 6.7% increase from the previous year. Of these clinic visits, 12.2% were new consults. No-shows to HCV clinic have historically been a problem, with 41.5% of new patients not attending their appointments in 28/9. In an effort to improve delivery of this service, an off-site clinic at Burnside Correctional Centre was developed in 29/1. It is hoped that by improving access this clinic will ultimately improve health outcomes for this group of patients by earlier identification of medical concerns and treatment needs. Figure 5 Hepatitis C Ambulatory Care Registrations 6 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Figure 6 Hepatitis C Clinic New and Return Ambulatory Care Registrations 3 Registrations New Return Total % New 21.2% 18.8% 7.7% 12.1% 12.2% HIV Program The HIV program is provided by another interdisciplinary team that includes physicians, nurses, pharmacists, nutritionists, psychologists, and spiritual care workers. HIV nurses are also available to see patients 5 days/week. Advice to patients (and their physicians) is provided over the telephone. Patients are seen as needed outside of the regularly scheduled clinic hours. Risk reduction advice to patients and their partners is provided and referrals to community services are also arranged. The clinical nurse specialist makes home visits as needed. There were 866 visits to the HIV Program in 212/13, representing a 3.6% decrease from the previous year. Of these clinic visits, 5.% were new consults. On average, there were 44 active HIV patients in 212/13, as compared to 383 active patients last year. 18 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES

115 Figure 7 HIV Program Ambulatory Care Registrations 16 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total STD Clinic The STD clinic is an evening walk-in clinic held twice weekly. The team is made up of family physicians and nurses. Two division members (Drs. Davis and Hatchette) attended this clinic on a rotating schedule in 212/13. In 212/13, there were 1,735 visits registered to the STD clinic, representing a 4.% increase from the previous year. Of these clinic visits, 44.3% were new consults. Figure 9 Infectious Diseases STD Ambulatory Care Registrations 2 18 Figure 1 Infectious Diseases STD Clinic New and Return Ambulatory Care Registrations 2, 1,8 1,6 1,4 1,2 1, New Return Total 1,276 1,344 1,413 1,668 1,735 % New 37.9% 32.9% 35.7% 46.7% 44.3% Registrations DIVISION OF INFECTIOUS DISEASES Figure 8 HIV Program New and Return Ambulatory Care Registrations 1,2 Registrations 1, Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total , , , , ,735 Medical Day Unit There were 69 patient visits registered in the Medical Day Unit under Infectious Diseases physicians in 212/ CodeMissing New Return Total % New 5.5% 2.9% 6.5% 4.6% 5.% DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES 19

116 DIVISION OF INFECTIOUS DISEASES Wait Times The table below shows the triage criteria used for new referrals in infectious diseases outpatient clinics. Table 3 Triage Category Examples only Standard Wait Time Emergent Meningitis Malaria Urgent Acute febrile illness NYD Acute febrile illness with focus Fever in traveler Immediate < 72 hrs Semi-urgent Chronic fever NYD (> 4 wks) < 4 wks Non-urgent Chronic HBV Chronic HCV HIV Chronic diarrhea Recurrent UTI 6 8 wks Figure 11 Figure 12 Figure 13 Infectious Diseases New Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Infectious Diseases New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Infectious Diseases New Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Days Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 1% 1% 1% 1% 1% 1% 1% 1% Source: PHS Data Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 96% 93% 98% 98% 91% 98% 96% 98% Source: PHS Data Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 94% 73% 62% 52% 74% 89% 8% 64% Source: PHS Data 11 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES

117 Patients Referred but Not Seen New referrals are occasionally sent back to the referring physician. Referrals are not seen either because treatment advice is given to the referring physician over the telephone or the referral was not appropriate for the Infectious Disease service. There were 87 referrals received that were not seen in 212/13. Clinic No Shows Patients are considered no show if they miss an appointment without calling to cancel or reschedule. The average no show rate for scheduled bookings to all ID practitioners in 212/13 was 1.7%, which is an increase from 1.4% the previous year. It should be noted that the no-show rate for new, non-urgent consults remains low relative to the 14.6% rate observed in 26/7; this is likely the result of the implementation of an automated reminder call system. DIVISION OF INFECTIOUS DISEASES Table 4 Table 5 No Show Infectious Diseases, QEII Health Sciences Centre Resource Booked No Show % No Show DH % IRD % LJ % SM % TH 2.% WS 4.% YL % JH % KS % FB 2.% Total 2, % Source: PHS Data No Show by Procedure Infectious Diseases, QEII Health Sciences Centre Procedure Booked No Show % No Show New Urgent 1.% New Semi-Urgent % New Non-Urgent % Return Visit 1, % HIV New % HIV Return % Hep C New % Hep C Return % Hep C Nursing % Pharmacy % Nursing % Leg Ulcer New 6.% Leg Ulcer Return 8.% Total 2, % Source: PHS Data DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES 111

118 DIVISION OF INFECTIOUS DISEASES Patient Demographics The figure below represents the distribution of outpatient residency within each District Health Authority in Nova Scotia in 212/13. In 212/13 there were 86 registrations of patients that reside outside the province of Nova Scotia. Table 6 Health District Population* Registrations Rate** 1 - South Shore District Health Authority 58, South West Nova District Health Authority 57, Annapolis Valley District Health Authority 81, Colchester East Hants District Health Authority 71, Cumberland Health Authority 31, Pictou County District Health 45, Guysborough Antigonish Strait Health Authority 43, Cape Breton District Health Authority 119, Capital District Health Authority 412,518 3, ***1 - Other Total 921,725 4, *Source: Nova Scotia Community Counts - Statistics Canada, Census of Population 212 Statistics ** Rate per 1, estimated population Education Undergraduate Medical Education All Infectious Diseases physicians contribute directly to undergraduate education by tutoring, lecturing, clinical demonstrations, evaluation, electives and course development. 3 undergraduate medical students (Med I and Med II) chose Infectious Diseases as an elective in the 212/13 academic year. 1 clinical clerks, including electives, did 4-week rotations through the division in the 212/13 academic year. Division members delivered 58 hours of Med I Clinical Skills, 8 hours of Med I Rotating Electives, 16 hours of Med I & II Case Based Learning (CBL), 24 hours of Med II Clinical Skills, 8 hours of Med III Clerkship Seminars and 9.5 hours as examiners for Med II and III OSCE in the 212/13 academic year. The figure below represents the distribution of outpatients by age group Nova Scotia in 212/13. Table 7 Age Group Population* Registrations Rate** , ,54 1, , , , , , , Total 921,725 4, *Source: Nova Scotia Community Counts - Statistics Canada, Census of Population 212 Statistics ** Rate per 1, estimated population Postgraduate Medical Education 49 residents from various disciplines rotated through the Infectious Diseases service for 4 weeks each during the 212/13 academic year. This includes inpatient and outpatient consultation experience and exposure to the microbiology laboratory. Evaluations of these rotations were very positive. Division members delivered 9 hours of Academic Half Day teaching, 1 hours as examiners for Resident OSCE, 5 hours of CaRMS File Review, 4 hours of CaRMS interviews, 149 hours of learning exams and 73 hours of plate rounds with house staff rotating on ID. 112 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES

119 Subspecialty Medical Education The Division of Infectious Diseases has an active subspecialty residency training program which is closely linked with the Medical Microbiology Resident Training Program. The program consists of formal lectures in the setting of an academic half-day and bedside teaching. No residents completed their training in the 212/13 academic year. Continuing Medical Education Infectious Diseases physicians provided 15 sessions presented to general practitioners, specialists and other health professionals in 212/13. Additionally, Saint Johnappointed members delivered 4 CME sessions and crossappointed members provided 24 CME sessions in 212/13. Research Division members have been involved in the following research activities: As a Clinician Scientist with the Division, Dr. McNeil s research program continues to focus on the evaluation of new vaccines targeted for adolescents and adults and on establishing Canadian data required to inform immunization policy for these groups. The majority of her work over 212/13 has related to her role as Principal Investigator for the PHAC/CIHR Influenza Research Network (PCIRN) Serious Outcomes Surveillance (SOS) Network. In 212 the Network was awarded $12,, over 3 years through a Collaborative Research Agreement with GlaxoSmithKline. Over the past year the Network has expanded to 43 institutions in 7 provinces, encompassing 18, acute care beds and making the SOS Network the largest adult acute care Network of its kind in Canada. In addition to influenza, the Network does comprehensive prospective surveillance for communityacquired pneumonia and invasive pneumococcal and meningococcal disease. This is also funded by CIHR and an Investigator Initiated Research grant from Pfizer Inc for $3,688,611 over 3 years. In addition to ongoing funding from CIHR, the Network has leveraged funding from industry and supports the activity of several subprojects funded by CIHR, Ontario Public Health, Physicians Services Incorporated in Ontario and provincial public health departments. The Network involves 2 academic collaborators from infectious diseases, infection prevention and control, geriatric medicine, public health, health economics, and health services research. It provides valuable information to policy-makers on burden of disease, associated healthcare costs, and effectiveness of immunization programs in preventing hospitalization and death. Findings have been presented at national and international meetings and data collected through the Network is the primary source of information on influenza-associated hospitalization reported in FluWatch. As Principal Investigator, Dr. McNeil has been invited to present the methodology and findings of the Network at meetings sponsored by the United States Centers for Disease Control and Prevention (CDC), the United States Department of Health and Human Services, and the WHO. Dr. McNeil continues to build on collaborations within Canada and internationally and engages regularly with the CDC-funded hospital surveillance Network in the United States, and i-move and EpiConcept, similar Networks in Europe. In 212/13, Dr. McNeil coordinated activities of the PCIRN Safety theme, enrolling 12, healthcare providers, including approximately 2 in Halifax, into safety trials of influenza vaccine. Dr. McNeil continues to collaborate on studies examining immune biomarkers as a predictor of influenza among vaccinated residents of long term care and to evaluate risk factors for influenza among healthcare workers. In addition to the above, Dr. McNeil continues to participate in clinical trials of new vaccines including shingles, HPV, adjuvanted seasonal influenza, high-dose influenza vaccines for the elderly, quadrivalent meningococcal, and herpes simplex vaccines. Within the Department of Medicine, she has continued to build collaborations with other groups, most notably with Hematology (and Medical Oncology) for the conduct of 3 clinical trials evaluating safety of a novel, inactivated varicella zoster vaccine in immunocompromised adults. Dr. McNeil is part of a team of investigators that has secured 1 years of funding from the Michael Smith Foundation for a multi-provincial evaluation of the impact of school-based HPV vaccine on long term clinical outcomes; she coordinates the Atlantic Canada sites in collaboration with provincial Public Health. She is coinvestigator on a CIHR-funded team grant exploring the acceptability and education needs of parents of young men regarding HPV vaccination of boys. Finally, as NS embarks on the provision of adult immunization by pharmacists, Dr. McNeil co-leads a new research team, along with Drs. Jennifer Isenor and Dr. DIVISION OF INFECTIOUS DISEASES DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES 113

120 DIVISION OF INFECTIOUS DISEASES Kathryn Slayter, which is exploring facilitators and barriers to pharmacists immunizing from the prospective of conventional immunization providers in the Maritimes and evaluating the impact of pharmacist immunizers in New Brunswick. Dr. Garduño s 1-year term as a Canada Research Chair (Tier II) Scientist came to an end in 213. His research interests continue to be in the study of waterborne (Legionella pneumophila and Aeromonas) and foodborne (Listeria monocytogenes) bacterial pathogens. 212/13 continued to focus on molecular mechanisms of pathogenesis and bacterial fitness. There were 5 publications in the past year on different aspects of Legionella pneumophila pathogenesis, but mainly on the role of the Legionellae chaperonin as a multifunctional protein with virulence functions. Dr. Garduno is currently operating with funding from NSERC to continue his work on the L. pneumophila chaperonin. The collaborations started in 28 with two French investigators on the topic of Legionella differentiation have continued. Two genes identified using this technology are being studied in my lab to determine whether or not they play a role in Legionella differentiation. The second collaboration, which involves the characterization of Legionella that differentiated inside ciliated protozoa, is now published. In addition, a new collaboration with Dr. Mauricio Terebiznik (University of Toronto) has been started to characterize the mechanism by which one of the differentiated forms of Legionella (Legionellae filaments) invade lung epithelial cells. This work will provide a better understanding of how the differentiation of Legionella into various developmental forms is important for its transmission from the environment to humans, and why Legionella is not transmitted from person to person. Dr. Thomas lab was awarded a NSHRF grant to support translational research projects to look at the microbiome that is associated with inflammatory bowel disease (IBD) and/or Crohn s colitis in partnership with researchers at the IWK Pediatric Gastroenterology Division. Recent outbreaks of pathogenic E. coli strains across Canada emphasize the relevance of the research in a national context but also with respect to the developing world. The laboratory has published 4 papers in leading journals within fiscal 212/13. The major advance has been the in-house development of a novel high throughput assay that quantitatively measures toxin secretion levels from pathogenic E. coli strains. Furthermore, laboratory conditions to study toxin secretion levels from pathogenic Vibrio species have been identified. The aforementioned projects are on-going. In March 213, a five year national grant was awarded to support Dr. Thomas work on pathogenic E. coli and Vibrio species. There were 16 peer-reviewed papers published by fulltime and jointly-appointed division members in the 212 Calendar year. Additionally, there were 5 peer-reviewed paper published by a Saint John-based member and 12 peer-reviewed papers published by cross-appointed division members in abstracts were presented at National/International scientific meetings by joint-appointed and full-time division members in 212/13; additionally, Saint Johnbased members presented 12 abstracts cross appointed members presented 19 abstracts. The Division generated $7,86,63 in research grants and industry contracts in 212/13, including funding held by Dr. McNeil at the IWK Health Centre. Administration Infectious Diseases division members perform the following administrative duties: Division Head, including all responsibilities of the position Hospital Epidemiologists Division members act as Medical Directors or Chairs for: West Wing Research Laboratory Antimicrobial Agents Subcommittee STD Clinic HIV Clinic Research HIV Research Division members, including joint and crossappointees, provided referee or editorial services to 46 journals/granting agencies in 212/ DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF INFECTIOUS DISEASES

121 Division of Medical Oncology DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF MEDICAL ONCOLOGY 115

122 DIVISION OF MEDICAL ONCOLOGY Physician Resources There were 17 (15.4 FTE) members in the Division of Medical Oncology in the 212/13 year. 11 full-time institution based in Halifax 2 part-time, institution based, in Halifax 2 full-time institution based in Cape Breton 1 part-time, institution based, in Cape Breton 1 part-time, institution based, in Kentville Dr. ArabZadeh will be joining the Division on July 1, 213 as a Clinical Associate, replacing Dr. Samad who has been accepted into the General Internal Medicine Residency Training Program at the University of Saskatchewan. Dr. Kirby will be retiring from the Division of Medical Oncology in the summer of 213. Divisional Highlights Drs. Davis, MacNeil, Snow and Morzycki co-hosted the fourth, highly successful Atlantic Canada conference on lung cancer. Guest speaker at this event was Dr. T. Jock Murray, Professor Emeritus, Dalhousie University, Halifax, NS. Drs. MacNeil and Morzycki hosted the Atlantic Canada Lung Cancer Molecular Testing Forum. Keynote speaker was Dr. Alice Shaw, MD, PhD from Massachusetts General Hospital. Dr. Wood co-chaired the 16 th Annual Atlantic Canada Oncology Group (ACOG) Symposium in Halifax with guest speakers Dr. Paul Bunn from University of Colorado and Dr. Mark Vincent from University of Western Ontario. Dr. Wood co-hosted the 6 th Annual Atlantic Canada Uro-oncology Meeting with keynote speakers Dr. Bernard Bochner from Memorial Sloan-Kettering Cancer Center (MSKCC) and Dr. Timothy Wilt from University of Minnesota. Dr. Snow was promoted to Assistant Professor in 212/13, and received the Medical Oncology Teacher of the year award. The Medical Oncology Residency Training Program, which received full Royal College Accreditation in February 212, is now under the leadership of Dr. Jeyakumar who succeeded Dr. Colwell in 212/13. New Programs, Partnerships & Innovations The Atlantic Canada Center for Lung Cancer Molecular Testing is now open and serving patients across Atlantic Canada. This is the first Center in Canada to provide multiplex testing for lung cancer. Work for the Nova Scotia Department of Health and Wellness Drs. Dorreen and Younis are members of the Cancer Systemic Therapy Policy Committee with the Nova Scotia Department of Health and Wellness. Quality and Patient Safety Dr. Wood is a co-applicant on a CIHR Network Catalyst Grant with the Kidney Cancer Research Network (KCRN). One of the priority initiatives with this grant is Quality of Kidney Cancer Care which Dr. Wood co-leads. Dr. Stephanie Snow is the Medical Oncology representative on the Cancer Care Nova Scotia (CCNS)-led clinical standards committee on establishing standard-of-care criteria for the management of patients diagnosed with rectal cancer. The final report on the recommendations made is due to be published in 213/ DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF MEDICAL ONCOLOGY

123 Public Education A variety of informative public lectures given from the Halifax Infirmary were recorded and broadcast on Eastlink TV during The presentations are planned and organized through CCNS. Topics include: Kidney Cancer Canada (KCC) Patient and Caregiver Meeting (Topic: Hope for Kidney Cancer Patients: Stages I, II, III & V), June 7, 212 (Dr. Wood). Kidney Cancer Canada (KCC) Patient and Caregiver Meeting (Topic: Current Treatment Upgrades to Kidney Cancer), December 6, 212 (Dr. Wood). Clinical Services All Emergency coverage, inpatient, and ambulatory and diagnostic clinical services for Nova Scotia were provided by Medical Oncologists based in Halifax, Cape Breton & Kentville. Specialized secondary and tertiary oncology care provided for Nova Scotia patients include: Chemotherapy program Satellite clinics in: New Glasgow (restarted in October 26), Antigonish, Inverness and Yarmouth. Inpatient Services There are 4 Medical Oncology inpatient beds located on unit 8A/8B at the VG site of the QEII Health Sciences Centre (QEII HSC). The occupancy rate for 212/13 was 16.8%. The average bed utilization was 4.1, including off-service patients, with an average length of stay (ALOS) of 7.3 days. Utilization of Medical Oncology inpatient services is illustrated in the graphs below. Additionally, Medical Oncologists provided 6 weeks of attending service on the MTU and 35 shifts as Internist on-call to the QEII HSC Emergency Department during the 212/13 academic year. DIVISION OF MEDICAL ONCOLOGY CCNS recognizes that engaging cancer patients and their families is key to enhancing and improving the cancer system. With that aim in mind, the Cancer Patient Family Network (CPFN) was created to provide a forum for patients, family members, and friends to share their experiences of the cancer care system. CCNS has developed a video in which patients and healthcare providers talk about what patient engagement is, and why it is important. They also provide examples of practical ways that patients have been able to use their personal experiences to help improve the cancer care system, such as participating in focus groups, creating new patient education materials, participating as a committee member to provide advice about clinical standards, or participating in a research study. Nova Scotia Cancer Centre Clinics Satellite Chemotherapy sites (24 sites throughout Nova Scotia) Emergency Coverage Medical Oncologists provided 24-hour, 7-day / week emergency and on-call inpatient consultation service for Capital Health. Figure 1 Medical Oncology Average Bed Utilization by Fiscal Year 5 Beds Used Avail DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF MEDICAL ONCOLOGY 117

124 DIVISION OF MEDICAL ONCOLOGY Figure 2 Medical Oncology Inpatient Bed Occupancy Rate by Fiscal Year 14% Percent Occupancy 12% 1% 8% 6% 4% 112.8% 123.9% 16.8% 11.9% 16.8% was already associated to Medical Oncology. There is still some refinement required to the transfers metric due to issues with how the service can be updated within STAR. Figure 4 Medical Oncology Inpatient Average Length of Stay (Days) by Fiscal Year Inpatient Demographics The following figures represent Medical Oncology inpatient distribution by age, gender and patient residency by health district across 212/ % of Medical Oncology inpatients resided within Capital Health District during the past year. This ratio is expected, given admission practices for cancer patients in Nova Scotia. Figure 5 2% % Days 6 4 Medical Oncology Inpatient Admissions Percent Distribution by Gender QEII Health Sciences Centre, patients were admitted and an additional 2 patients were transferred into Medical Oncology beds during 212/13, representing a 6.6% increase in demand relative to the previous year Male 43% Female 57% Figure 3 Medical Oncology Inpatient Admissions and In-Hospital Transfers In by Fiscal Year 25 Admissions and Transfers Figure 6 Medical Oncology Inpatient Admissions Percent Distribution by Age and Gender QEII Health Sciences Centre, % Tranfers In Admits Total The Transfers in reports previously included all transfers to Medical Oncology which meant a large number of those transfers were the same patient being relocated. The query has been revised to exclude transfers where the service 35% 36% 3% 29% 28% 25% 23% 2% 22% 15% 16% 16% 13% 1% 9% 5% 5% 2% % % 2% % Female Male 118 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF MEDICAL ONCOLOGY

125 Figure 7 Medical Oncology Inpatient Admissions Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, Non Capital District: 31 Out of Province: 1 Capital District: 157 Ambulatory Care Medical Oncology ambulatory care included activity in the Nova Scotia Cancer Centre based at the QEII HSC, the Cape Breton Regional Hospital in Sydney and Valley Regional Hospital in Kentville as well as satellite services in New Glasgow, Antigonish, Inverness and Yarmouth. In Halifax there were 1,9 patients registered for Medical Oncology clinics in 212/13, representing a 1.9% decrease from the previous year. There were an additional 7,974 chart checks performed in 212/13 not reported in the following figures. There were 34 registrations in New Glasgow in 212/13, representing an 7.6% increase relative to the previous year. Of the actual patient visits in 212/13, 16.2% were new consults. Figure 9 Medical Oncology Clinic Registrations by Type Aberdeen Hospital, New Glasgow, DIVISION OF MEDICAL ONCOLOGY Of actual patient visits to the Halifax clinic in 212/13, 19.1% were new consults. Registrations Figure Inpatient Consultations As reported by Physician Services, there were 37 inpatient consults for the Halifax-based Medical Oncologists during 212/13. This figure also includes activity while on service to the Department of Medicine MTU or Internist on-call rotations. Medical Oncology Clinic Registrations by Type 12, Registrations 9, 6, 3, Other Family New 1,652 1,729 1,97 2,34 2,77 Return 7,85 7,942 8,653 9,75 8,814 Total 9,52 9,672 1,626 11,113 1,9 Source: OPIS Data New Return Total Source: OPIS Data Halifax-based Medical Oncologists continued to provide satellite services to Aberdeen Hospital in New Glasgow and Yarmouth Regional Hospital in Yarmouth in 212/13. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF MEDICAL ONCOLOGY 119

126 DIVISION OF MEDICAL ONCOLOGY Additionally, there were 858 registrations in Yarmouth in 212/13, representing a 3.5% increase relative to the previous year. Of the actual patient visits in 212/13, 12.6% were new consults. It should be noted that a Medical Oncology Telehealth service was started between the QEII HSC and Yarmouth Regional Hospital Cancer Centre in February 21. Figure 1 Medical Oncology Clinic Registrations by Type Yarmouth Regional Hospital, , The provision of Medical Oncology services at Valley Regional Hospital in Kentville commenced in July 27 with the recruitment of a locally-based Medical Oncologist; there were 1,378 Medical Oncology registrations in 212/13, which represents an increase of 13.% compared to the previous fiscal year. Of the actual patient visits in 212/13, 1.9% were new consults. Figure 11 Medical Oncology Clinic Registrations by Type Valley Regional Hospital, ,5 Cape Breton-based Medical Oncologists continued to provide services to the Cape Breton Regional Hospital in Sydney as well as satellite clinics at St. Martha s Hospital in Antigonish and Inverness Consolidated Memorial Hospital in Inverness in 212/13. In Sydney there were 3,485 patients registered for Medical Oncology clinics in 212/13, representing a 28.4% decrease from the previous year. Of actual patient visits to the Sydney clinic in 212/13, 17.% were new consults. Figure 12 Registrations Registrations 1, 5 Medical Oncology Clinic Registrations by Type Cape Breton Regional Hospital, , Registrations 5, 4, 3, Other New Return Total Source: OPIS Data Other 3 5 New Return 1,91 1,61 1,39 1,62 1,223 Total 1,239 1,29 1,197 1,219 1,378 Source: OPIS Data 2, 1, Other 24 Family New Return 4,195 3,412 3,392 4,277 2,865 Total 4,71 3,947 4,95 4,868 3,485 Source: OPIS Data 12 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF MEDICAL ONCOLOGY

127 There were 282 registrations in Antigonish in 212/13, which represents a 6.8% increase from the previous year. Of the actual patient visits in 212/13, 2.1% were new consults. Figure 13 Medical Oncology Clinic Registrations by Type St. Martha's Hospital, Antigonish, ,4 Registrations 1,2 1, Figure 14 Medical Oncology Clinic Registrations by Type Inverness Consolidated Memorial Hospital, Registrations Other 1 Family 1 New Return Total Source: OPIS Data Clinical Activity per Clinical FTE In 1995 a task force looked at the average workload of a Medical Oncologist, incorporating the number of followup ambulatory visits generated per new consult. This analysis took into account the different stages, treatments, tumor sites and incidence of each referral-type to reach a surrogate marker of 16 new consults per full-time Medical Oncologist per year. This number is still used by some provinces to calculate manpower needs however workload has increased due to increasing lines of therapy and new indications. The consults per week in the table below reflect the workload of the Halifax-based division members compared to this national standard. This figure has been steadily above standard across the last 5 fiscal years. DIVISION OF MEDICAL ONCOLOGY Family 1 New Return 1, Total 1, Source: OPIS Data The provision of Medical Oncology services at Inverness Consolidated Memorial Hospital in Inverness commenced in January 27; there were 151 Medical Oncology registrations in 212/13 representing a 2.% increase compared to the previous year. Of the actual patient visits in 212/13, 9.9% were new consults. Figure 15 Medical Oncology Average New Registrations per Week per Clinical FTE QEII, Aberdeen, Yarmouth, New Registrations New visits per FTE per week Recommended Standard Source: OPIS Data DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF MEDICAL ONCOLOGY 121

128 DIVISION OF MEDICAL ONCOLOGY Chemotherapy Medical Oncologists have responsibilities to monitor patients receiving chemotherapy in the Nova Scotia Cancer Centre at the QEII HSC. During 212/13, there were 8,55 appointments for chemotherapy treatment, representing an 8.6% decrease relative to the previous year. Figure 16 Medical Oncology Registrations for Chemotherapy by Type 1, Medical Oncologists in Cape Breton were responsible for monitoring patients receiving chemotherapy at Cape Breton Regional Hospital. During 212/13, there were 5,57 registrations for chemotherapy treatment, representing a 1.7% decrease relative to the previous year. Figure 17 Medical Oncology Registrations for Chemotherapy by Type Cape Breton Regional Hospital, , 5, Medical Day Unit There were 52 patient visits registered under Medical Oncologists in the Medical Day Unit in 212/13. 8, Registrations 4, 3, Registrations 6, 4, 2, 1, 2, New Return 7,57 7,273 8,19 7,934 7,678 Total 8,161 7,849 8,649 8,558 8,55 Source: OPIS/PHS Data New Return 4,391 4,79 4,753 4,876 4,895 Total 4,653 5,34 4,976 5,142 5,57 Source: OPIS Data 122 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF MEDICAL ONCOLOGY

129 Education Medical Oncologists contributed significantly to educational activities during the fiscal year 212/13. This division provided oncology-specific teaching and education to undergraduates and postgraduates rotating through the division, as well as providing a strong commitment to the educational programs of the Department and Faculty of Medicine. Sub-specialty Medical Education The Division of Medical Oncology offers a two-year Medical Oncology residency-training program, fully accredited by the Royal College of Physicians & Surgeons of Canada. Medical Oncology residents are provided an opportunity to have their own ½ day clinics to see patients under the direction of specific Medical Oncologists. Research A strong commitment to clinical research has been maintained despite reduced physician resources. This is a testament to the productivity of members of the Division. Dr. Younis was awarded a 5-year Clinical Research Scholarship in October 28, and continues to work on economic evaluation of systemic therapies in breast cancer. DIVISION OF MEDICAL ONCOLOGY Undergraduate Medical Education Medical Oncologists contributed directly to undergraduate education by tutoring, lecturing, clinical demonstrations, evaluation, electives and course development. 9 Med 4 electives and 4 undergraduate electives rotated through the division in the 212/13 academic year. Division members delivered 116 hours of Med I Clinical Skills, 8 hours of Med I Rotating Elective, 32 hours as tutors for Med I & II Case Based Learning (CBL), 48 hours of Med II Clinical Skills Consolidation and 32.5 hours as examiners for Med II and Med III OSCE in the 212/13 academic year. Postgraduate Medical Education There were 3 residents were enrolled in the Medical Oncology Residency Training Program during the 212/13 academic year. Dr. Head completed her Medical Oncology residency training in January 213, and accepted a position as a Clinical Associate at the Queen Elizabeth Hospital in Charlottetown, PE. Drs. Lamond and Karachiwala successfully completed their Royal College Internal Medicine exams in May 213. Dr. Bains from Memorial University, Newfoundland will be joining the Medical Oncology Residency Training Program in July 213. Continuing Medical Education Medical Oncologists were active in the provision of continuing medical education, with 34 sessions presented annually to general practitioners, specialists and other trainees in 212/13. Dr. Snow received the 212 award for the highest number of accruals to clinical trials There were 2 peer-reviewed papers published by division members in 212/13. 9 abstracts were presented at National/International scientific meetings in 212/13. Medical oncologists provide referee and editorial services for 54 journals/granting agencies during 212/13. The Division generated $1,4,17 during 213/14 in research grants and industry contracts. 15 residents from multiple specialties (Radiology, Radiation Oncology and Pathology) rotated through the Medical Oncology service during the 212/13 academic year, including 7 Core Internal Medicine resident rotations. Additionally, division members delivered 6 hours of Academic Half Day teaching, 1 hours as examiners for Resident OSCE, 5 hours of CaRMS file review, 4 hours of CaRMS interviews and 1 hours as examiners for Resident OSCE. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF MEDICAL ONCOLOGY 123

130 DIVISION OF MEDICAL ONCOLOGY Administration Medical Oncologists performed the following administrative activities: Division Head/Service Chief, including all responsibilities of the position Program Director & Chair, Medical Oncology Residency Training Program Chair, Oncology Grand Rounds Committee Chair, EPIC & ODYSSEY Data Safety & Monitoring Board, University of Ottawa Chair, Clinical Trials Symposium, Canadian Cancer Research Conference Chair, Atlantic Canada Oncology Network Co-Chair, Organizing Committee, Atlantic Canadian Oncology Group Annual (ACOG) Symposium Chair, Medical Oncology Morbidity and Mortality Committee Chair, Oncology Therapy Subcommittee of DD&T Director, Atlantic Clinical Cancer Research Unit (ACCRU) Chair, Clinical Trials Working Group Director, Medical Oncology Undergraduate Medical Education Program Co-Head, Integration Unit, Dalhousie Faculty of Medicine Chair, Healthy Eating Active Living (HEAL) Cape Breton Chair, Cape Breton Cancer Symposium Co-Chair, Clinical Trials Review Committee, Cape Breton Regional Hospital Chair, Kidney Cancer Canada Medical Advisory Board Chair, Canadian Neuroendocrine Tumor Society Annual Conference Co-Chair, Atlantic Uro-oncology Meeting Cancer care program site chairs and co chairs include: Chair, GI Tumor Site Team Co-Chair, Breast Tumor Site Team Co-Chair, Thoracic Tumor Site Team Divisional members assumed a leadership role in administration by participating in divisional, Department of Medicine, Capital Health, Dalhousie University and other affiliated organizational committees. 124 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF MEDICAL ONCOLOGY

131 Division of Nephrology DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY 125

132 DIVISION OF NEPHROLOGY Our Patient Care The Renal Program strives for quality, and as such, has many different quality teams that each focus on improving the safety and quality that is delivered. The Renal Program is also committed to improving the quality of renal care and is actively involved in the research community. The Renal Program is looking towards the future with the creation of the Renal Palliation and Therapeutic Harmonization (PATH) clinic, the promotion of home therapies, and the transitioning of satellite dialysis units to the local health authorities in which they are located. New Programs, Partnerships & Innovations The Renal Program received approval to build a new dialysis unit at the HI. Work on the initial planning stages has commenced and an architect has been brought in to develop detailed plans. A new 1-station satellite hemodialysis unit opened in Colchester East Hants Health Center in December, 212. This replaced the existing 3-station unit. In the fall of 212, the Department of Health and Wellness announced funding for the design phase of a new 12-station satellite dialysis unit at Valley Regional Hospital that will replace the existing 6-station unit in the Western King s Memorial Health Centre. The renal program has developed a multi-pronged approach to expanding home therapies, including the production of a home dialysis education video in the renal clinic, and a study measuring pre and post scores of an educational intervention on the perceptions of home dialysis of in-centre hemodialysis unit nurses. Our Team Dr. Karthik Tennankore is finishing his Home Therapies Fellowship in Toronto, and has also completed the first half of a Masters in Public Health (Clin Epi) at the Harvard School of Public Health. Dr. Tennankore will join the Division of Nephrology in August 213. Congratulations to Dr. Steven Soroka on his appointment to Vice President of Medicine January 1, 213. Dr. Ken West assumed the day-to-day running of the Renal Program. Dr. Tammy Keough-Ryan on her promotion to full Professor effective July 1, 212. Dr. Penelope Poyah on her promotion to Assistant Professor effective July 1, 212 The Renal Quality and Patient Safety Team on being awarded the Capital Health patient Safety Team Award December 6, 212. Welcome Aboard to In March 213, Dr. Ken West began a chronic renal failure clinic at St. Martha s Regional Hospital. The clinic runs approximately every three to four months, and sees approximately 1 new patients and 4-6 returns from previous clinics. Dr. Scaria George, who joined the Nephrology team in November 212 as a hospital-based fellow for a two year term. A Fond Farewell to Dr. Meteb Al Bugami who completed his year of Transplant training with us. 126 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY

133 Work for the Nova Scotia Department of Health and Wellness Dr. Ken West has been a member of the Nova Scotia Renal Program Advisory Council since his appointment in August 21. In May 213, Dr. Neil Finkle was appointed as Clinical Advisor for the Nova Scotia Renal Program. Dr. Finkle will serve a two-year term (.1 FTE commitment) with the program providing clinical expertise and advice on renal health for the province. Quality Patient Safety There are several quality care teams with physician coleads within the Renal Program. These teams include the Renal Program Quality and Patient Safety Team, Anemia Management Quality Team, Kidney Patient Advocacy Committee, Mineral Metabolism Team, PD Quality Team, Practice and Safety Team, Professional Practice Team, and Vascular Access Team. Shadow Charts Average Length of Stay Patients are managed primarily by a staff Nephrologist. They work closely with nursing to identify barriers to discharge. Clinical Activities & Services All Emergency coverage, inpatient, ambulatory, dialysis and general Nephrology services are provided to patients of Nova Scotia (except Cape Breton and Yarmouth) by Capital Health Nephrologists. Back-up consultative services are provided to the province of PEI. Issues of Appropriateness of Care David Landry, NP, initiated the Renal PATH (Palliative and Therapeutic Harmonization) clinic approximately one year ago. The PATH clinic is based on the model developed by Drs. Laurie Mallery and Page Moorhouse. This program helps identify frailty in elderly patients and helps the patient s families and caregivers make healthcare decisions that are in the best interests of the patient and lead to the best quality of life. Service Delivery Summary Specialized care for patients in the Capital District Health Authority and tertiary care for the region, including: General Nephrology In Centre Hemodialysis (QEII Hospital & Dartmouth General Hospital) Community Dialysis: Hemodialysis and Peritoneal Dialysis across NS & backup consultations to PEI Chronic Renal Insufficiency Clinic Kidney and Kidney/Pancreas Transplantation (Atlantic Canada) Fabry Disease Clinic DIVISION OF NEPHROLOGY The division no longer has shadow charts. All materials are sent to HPF. Working folders are used for outpatients. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY 127

134 DIVISION OF NEPHROLOGY Inpatient Services The number of inpatient beds available for 212/13 include: Table 1 Unit/Designation # Beds General Nephrology (6B VG) 1 Transplant 9 Total 19 Inpatient activity for nephrology beds has fluctuated over the last five years, as noted in the next several graphs. The average occupancy for Nephrology beds for 212/13 was 6.3% which is lower than the previous year. Figure 1 Nephrology Inpatient Bed Occupancy Rate by Fiscal Year 14% Percent Occupancy 12% 1% 8% 6% 4% 2% 118.2% 123.8% 78.2% 64.5% 6.3% % Figure 2 The following graphs provide annual data for Nephrology and Renal Transplant inpatient activity. There was an average of 17 Nephrology Inpatient admissions per month for a total of 21 admissions. 59.5% of the admissions to Nephrology were patients from the Capital Health District area whereas 35.2% were from other districts throughout the province, and 5.2% were from out of province. The number of admissions to the nephrology service increased by 1.9% compared to the previous year. Figure 3 Nephrology Inpatient Admissions Nephrology Average Bed Utilization by Fiscal Year 14 Admissions 1 12 Beds Used Avail DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY

135 Figure 4 Nephrology Inpatient Admissions Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, Non Capital District: 74 Out of Province: 11 Figure 6 Renal Transplant Inpatient Admissions Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, Out of Province: 51 Capital District: 58 The graph below provides the alternate level of care data for Nephrology patients. These data have not been censored for outliers. In the fiscal year 211/12 there were 9 ALC patients with an average of 5 ALC days per month whereas in 212/13 there were 4 ALC patients with an average of 7 ALC days per month. Figure 8 DIVISION OF NEPHROLOGY Nephrology Inpatients Waiting in Alternate Level of Care 7 Capital District: There was an average of 14 Renal Transplant admissions per month during the fiscal year 212/13 which is a decrease of 2.8% from the year 211/12. The ALOS decreased from 12. days in 211/12 to 9.3 days in 212/13. Approximately 35.4% of these admissions were from Capital Health District and 33.5% were from other provincial health districts whereas 31.1% were from other provinces. Figure 5 Renal Transplant Inpatient Admissions 25 Non Capital District: 55 The average length of stay (ALOS) in Nephrology for the fiscal year 212/13 was 9.9 days for Nephrology and 9.3 days for Renal Transplant. These data include the length of stay for Alternate Level of Care (ALC) patients. Figure 7 Nephrology Inpatient Average Length of Stay (Days) by Fiscal Year 15 Days Total ALC Days ALC Days # Patients Avg. Days / Month Source: Social Work / Manual Admissions Nephrology Renal Transplant DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY 129

136 DIVISION OF NEPHROLOGY Dialysis The following graphs provide an overview of the activity for Dialysis. There has been a decrease in the total number of Acute Procedures from 914 procedures in 211/12 to 84 in 212/13. There has been a 12.8% increase in the total number of Acute Dialysis Patients (29) in 212/13 from the year 211/12 (257). Figure 9 Figure 11 Community Hemodialysis Patients on Program Avg. # of Patients 132 Berwick, Liverpool, Pictou, Port Hawkesbury, Sherbrooke, Springhill, and Truro. Figure 13 Hemodialysis Registrations , Registrations 6, 5, 4, 3, In-Centre Hemodialysis Program (Acute) 1,4 Procedures 1,2 1, Procedures 1,25 1,198 1, Patients Source: Dialysis Data Figure 1 CDHA Hospital Hemodialysis Program (Chronic) , Procedures 4, 3, 2, 1, Procedures DGH 7,454 6,998 6,79 7,94 7,957 Procedures VG 3,229 3,785 32,432 33,142 31,22 * VG Avg. # pts * DGH Avg. # pts Total Procedures 37,683 37,783 39,141 4,236 38,979 * Avg. # pts. - Average # patients treated/month for Year Source: Dialysis Data Source: Dialysis Data The trend toward decreasing utilization of peritoneal dialysis is attributable to a number of factors including an aging population with insufficient supports at home, and the relatively easy access to hemodialysis in satellite clinics throughout the province. Figure 12 Community Peritoneal Dialysis Patients 125 Avg. # of Patients Source: Dialysis Data There were 57,212 hemodialysis procedures performed during the year 212/13. The Satellite value in the figure below consists of the following sites: Antigonish, Baddeck, , 1, DGH 7,454 6,998 6,79 7,94 7,957 Acute Dialysis 1,25 1,198 1, VG 3,229 3,785 32,432 33,142 31,22 Satellites 13,332 14,22 14,96 15,816 17,429 Total 52,4 53,21 54,346 56,966 57,212 Source: Dialysis Data A different data source (STAR) is used to produce the graph below. The Dialysis Program does not track patient residency information and since the STAR registration data will not completely reconcile, this can only be used to represent a sample distribution based on the data available. Figure 14 Renal Dialysis Registrations Percent Distribution of Patient Residency by Health District Capital Health, SWH:.7% NB, NF, PEI: 1.4% SSH: 9.5% PCHA: 6.% GASHA: 2.2% CHA: 4.9% CEHHA: 8.3% CBDHA:.8% AVDHA: 8.9% CDHA: 57.4% 13 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY

137 Ambulatory Care The number of ambulatory visits (excluding Dialysis) for the year 212/13 was 4,319 compared to 4,582 visits for the year 211/12. There were an additional 594 chart checks performed in 212/13 not reported in the following figures. Figure 15 There was a 5.7% decrease in registrations from the previous year. On average, 18.8% of the patients seen in the Nephrology Clinic during 212/13 were new patients. Figure 16 4th Floor Dickson Nephrology Clinic (including non-physician visits) New and Return Ambulatory Clinic Registrations 5, 4, In 212/13, approximately 55.3% of the patients in nephrology clinics were male and 44.7% female. Figure 18 4th Floor Dickson Nephrology Clinic Registrations Percent Distribution by Gender QEII Health Sciences Centre, DIVISION OF NEPHROLOGY 4th Floor Dickson Nephrology Ambulatory Registrations (including non-physician visits) # Patient Registrations 5, 4,5 4, 3,5 3, 2,5 2, 1,5 1, Pre-kidney Pancreas 15 1 Nph Ren Dial Assess Nephrology Research Predialysis Educ 15 1 Transplant Donor TRN Pre-kidney Nph Fabry Disease Nursing Consult Chronic Renal Insuf Nephrology 3,723 3,79 3,494 3,931 3,118 Total 4,556 4,547 4,168 4,582 4,319 Registrations 3, 2, 1, Unknown New Return 3,55 3,538 3,336 3,611 3,51 Total 4,556 4,547 4,168 4,582 4,319 % New 21.8% 21.6% 19.7% 19.8% 18.8% Figure 17 4th Floor Dickson Nephrology Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, Figure 19 Male 55.3% 4th Floor Dickson Nephrology Clinic Registrations Percent Distribution by Age and Gender QEII Health Sciences Centre, Age Group % 1.3% Female 44.7% Other: 4 NB, NF, PEI: 72 SWH: % -19.4% 12.% 26.7% SSH: % 23.5% % 14.2% PCHA: 196 GASHA: 68 CDHA: 2, % 12.4% CHA: % 5.% % 4.3% CEHHA: %.5% CBDHA: 39 AVDHA: % 3.% 2.% 1.%.% 1.% 2.% 3.% 4.% Female Male **excludes chart check registrations DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY 131

138 DIVISION OF NEPHROLOGY Medical Day Unit The graph below reflects the volume of Nephrology patients receiving therapeutic treatments in the Medical Day Unit. These registrations include patient visits for renal biopsy, intravenous iron, enzyme therapy and blood transfusions. Figure 2 Nephrology Medical Day Unit Ambulatory Care Registrations 6 Registrations Triage Guidelines and Wait Times Table 2 Guidelines for Triage of New Referrals to Nephrology Outpatient Clinics Emergent Examples include: Life threatening uremic symptoms e.g. marked hyperkalemia, pulmonary oedema, pericarditis Priority 1 Examples include: End stage renal disease Rapid decline in renal function over days to weeks Severe uncontrolled symptoms of kidney disease Priority 2 Examples include: Subacute renal failure, with deterioration over weeks to months Mild to moderate symptoms of kidney disease Standard Wait Time Immediately (24 hours) Within 1 week (7 Days) Within 4 weeks Priority 3 Examples include: Stable, chronic renal failure, decline over months to years Mild symptoms or signs of kidney disease Within 3 months Priority 4 Examples include: Minor abnormalities in blood, urine or radiological tests e.g. kidney cysts on ultrasound; urine protein <3 mg/day without other kidney or systemic disease Within 1 year 132 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY

139 The following graphs represent actual wait times for patients seen during 212/13. Figure 21 Nephrology New Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 8% 68% 5% 67% 71% 43% 59% 5% Source: PHS Data Figure 23 Nephrology New Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 49% 5% 1% 8% 4% 14% 39% 2% Source: PHS Data Transplant The total number of transplant clinics visits has decreased in 212/13 by 4.4%. There were 1,917 clinic visits in 212/13 compared to 2,6 visits in 211/12. Figure 24 Transplant Clinic Note: This data represents the total volume for surgeons & nephrologists. 2,5 # of Patient Registrations 2, 1,5 1, 5 DIVISION OF NEPHROLOGY Figure 22 Nephrology New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Kidney Pancreas Renal Transplant 1,838 2,144 2,55 1,985 1,94 Total 1,912 2,222 2,18 2,6 1, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 18% 53% 81% 67% 53% 6% 27% 39% Source: PHS Data DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY 133

140 DIVISION OF NEPHROLOGY The following graph indicates the volume of transplant activity provided by Nephrology. Nephrologists saw 96% of transplant clinic patients compared to 94.8% the previous year. This activity has a significant impact on workload. Figure 25 Nephrology Volume of Transplant Activity Provided by Nephrologists 1,2 Registrations 1, Nephrologist A Nephrologist B 788 1, Nephrologist C Nephrologist D Nephrologist E Neph Tot 1,769 2,11 1,987 1,92 1,84 Transpl Tot 1,912 2,222 2,18 2,6 1,917 Neph % 92.5% 95.% 94.3% 94.8% 96.% Renal Transplant Wait List Patient Evaluations Much work is required to support the Renal Transplant Wait List. Patients who are referred for renal transplantation require evaluation as to their eligibility. This work is in addition to patient assessment and follow-up that is provided in Nephrology Clinic. These patients are from all four Atlantic Provinces. During the fiscal year 212/13 there was 149 new referrals and 231 reviews completed. Potential live donors also require intensive evaluations. There were 21 new referrals in 212/13 and 112 reviews completed. Figure 26 Evaluations of Patients on the Renal Transplant Wait List 3 Patients Figure 27 Evaluations of Patients on the Renal Transplant Potential Live Donors 15 Patients New Referrals Reviews Source: Manual Mean Mean A measure monitored by the Emergency Department as an indicator of patient care quality is the length of time (in hours) from when a consultation request is made to the time an admit order is placed. A benchmark of 2 hours has been set by the ED as a standard to ensure appropriate patient flow New Referrals Reviews Mean Mean Source: Manual Figure 28 Nephrology Average Wait Time - Consult Request to Admit Ordered Capital Health, April 28 - March Average Wait Time - Consult Request to Admit Ordered (hrs) Benchmark Volume Volume *23-8 and 8-23 are based on consult request times. *Times included when the consulting service is also the admitting service Source: EDIS 134 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY

141 Education Undergraduate Medical Education Dr. Christine Dipchand is Head of the Clinical Skills Program for undergraduate medical students at Dalhousie s Faculty of Medicine. Dr. Finkle is Head of Medicine Clerkship for the Department of Medicine. CaRMS interviews for 4 hours. Dr. Mike West served as Attending Physician on the MTU for a total of 2 weeks in 212/13 and nephrologists also provided 21 nights of ED On-call coverage. Dr. Talal Alfaadhel began a two year Nephrology residency with the division in July 212. Research Drs. Soroka, M. West, and Kiberd have ongoing industry funded research in the areas of fabry disease, transplantation, kidney disease and treatment, and dialysis. The Division generated a total of 1,459,87 during 212/13 in research grants and industry contracts. DIVISION OF NEPHROLOGY 3 Med III-IV clerks rotated through the Division in 212/13 including: 16 Med 3 core clerkship rotations and 1 Med 3 elective rotation, 1 IMU elective, and 12 Med 4 electives. Dr. Karthik Tennankore, a former Nephrology resident, re-joined the division in July 212 to further his training in dialysis therapies and research methods. Nephrology Faculty provided 8 hours of lectures to the Medicine clerkship seminar series. Continuing Medical Education Dr. Neil Finkle provided 16 hours as a tutor in the Med 1 & 2 Case Based Learning Program. Four nephrologists provided 48 hours of Clinical Skills teaching in the Med 2 Consolidation Unit. The Division focuses on the continuing education of primary care practitioners and general internists particularly regarding the appropriate referral and management of diabetic nephropathy and other causes of chronic renal failure. Nephrologists provided 8 hours as examiners for the Med 2 OSCEs, and 11.5 hours as examiners for the Med 3 OSCEs in 212/13. Postgraduate Medical Education The Division provided 32 four week rotations for residents in 212/13, including 28 for core Internal Medicine residents and 4 rotations for residents.. Nephrologists participated in the Core Internal Medicine Academic Half day a total of 1 hours in 212/13, and division physicians acted as examiners for the core Internal Medicine resident OSCE for 1 hours. Nephrologists participated in CARMS File Reviews for a total of 1 hours in 212/13 and also participated in DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY 135

142 DIVISION OF NEPHROLOGY Administration Division Head, including all responsibilities of the position Division members act as Chairs/Directors for: Chair, Dialysis Program Executive Committee Chair Morbidity & Mortality Committee Medical Director, Live Kidney Donor Program Chair, Kidney Transplant Waitlist Committee Director, Nephrology Residency Training Program Director, Renal Clinic and Chronic Renal Insufficiency Clinic Coordinator, Postgraduate Nephrology Medical Education Medical Director, NS & PEI Peritoneal Dialysis Program Medical Director, Kidney Transplant Program Medical Director, Kidney-Pancreas Transplant Program Director, Undergraduate Nephrology Medical Education Medical Director, Nephrology Clinical Trials Program Director, In-Centre Hemodialysis Director, Nova Scotia Fabry Disease Clinic Medical Advisor Nova Scotia Provincial Renal Program Director, Research Coordinator, Monthly Renal Biopsy Rounds Chair, Nephrology Finance Committee Divisional members assume a leadership role in administration by participating in hospital, divisional, Department of Medicine and university committees as well as committees associated with affiliated organizations. Dr. Kenneth West is currently President of Capital Health s District Medical Staff Association and will serve in this capacity for a two year term. 136 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEPHROLOGY

143 Division of Neurology DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY 137

144 DIVISION OF NEUROLOGY Physician Resources FTE neurologists 11 neurologists are hospital-based; 5 are communitybased but provide varying degrees of in-hospital patient care and teaching; and 6 neurologist is exclusively community-based. Division Highlights Dr. Sultan Darvesh was Appointed Assistant Dean of Research-Clinical Departments, Faculty of Medicine, Dalhousie University. December 212. Dr. Colin Josephson was the recipient of The Canadian Society of Clinical Neurophysiologists (CSCN) National Clinical Fellowship in Epilepsy and Electroencephalography for and The Canadian League Against Epilepsy (CLAE) Mary Anne Lee Award for best Canadian neurology or neurosurgery resident research. Dr. Stephen Douglas, PGY1 joined the Adult Neurology Residency Training Program in July 212 as the CaRMS PGY1 match and Dr. Ayoub Dakson, PGY1 joined as a VISA trainee from Kuwait. Dr. James Mathers, PGY2 joined the program from Physical Medicine and Rehabilitation. Dr. Ayoub Dakson transferred to the Division of Neurosurgery Residency Training Program at Dalhousie University in January 213. Dr. Jock Murray was the recipient of the Queen Elizabeth II Diamond Jubilee medal and an Honorary Doctor of Fine Arts by the Nova Scotia College of Art and Design on May 13, 212 Dr. Bernd Pohlmann-Eden received an unrestricted grant of $1, to support the 2 nd Halifax International Epilepsy Conference under his leadership together with Dr. Donald Weaver. Dr. Mark Sadler won an award from the International League Against Epilepsy (North American Commission) for design and implementation of the First Halifax-Jeddah, Saudi Arabia Temporal presentation Lobe Epilepsy Surgery Course. Dr. Heather Rigby graduated from her Masters of Medical Education Studies in conjunction with her ongoing Neurology Residency Program, and published her research in Neurology. Additionally, she was the recipient of the Samuel R. McLaughlin Fellowship Award to enable her to pursue further training in movement disorders at the Mayo Clinic in Scottsdale, AZ. 138 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY

145 Clinical Activity The Neurology Service includes an in-patient unit located on Ward 8.1 at the Halifax Infirmary Site of the QEII HSC consisting of the Stroke Service and General Neurology Service; there were 69 admissions in 212/13 with an inpatient occupancy rate of 11.2%. The Acute Stroke Unit provided care for 455 stroke patients in 212/13. Although the majority of these individuals were residents of Capital Health, the unit also treats people from other District Health Authorities, the Maritime Provinces, and beyond. The Acute Stroke Unit and Team also serve as a provincial resource for the training of personnel from other District Stroke Programs. The District Stroke Program, under the medical leadership of Drs. Stephen Phillips, Gordon Gubitz, and Anita Mountain (Division of Physical Medicine and Rehabilitation) continues to evolve within the Provincial Stroke System, which is directed by Cardiovascular Health Nova Scotia. There is also an active consultation service that evaluates in-patients across services at the Halifax Infirmary site, Victoria General site, Nova Scotia Rehabilitation Centre, and IWK/Grace Health Centre. Neurology provided approximately 446 consultations to other inpatient services, not including the QEII HSC Emergency Department (ED), in 212/13. The Neurology Service also includes ambulatory subspecialty clinics located on the 4th floor ambulatory care area at the Halifax Infirmary site. Additionally, Dr. Sarah Kirby provides neuro-oncology clinics and Dr. Charles Maxner provides neuro-ophthalmology clinics at the VG site. Dr. Timothy Benstead provides an EMG collaborative clinic with the Department of Otolaryngology at the Dickson Centre. Additionally, the Division has affiliated EMG and EEG labs. Dr. Virender Bhan and the care team affiliated with the Dalhousie MS Research Unit Clinic (DMSRU) have continued to develop care programs for the patient cohort with Multiple Sclerosis (MS). In conjunction with Dr. Christine Short of the Division of Physical Medicine and Rehabilitation, and with administrative leaders of Capital Health, the MS Clinic is now fully integrated at the NS Rehabilitation Centre. Overall, the move has been a success for MS Clinic staff (research and clinical) and most importantly, our patients like it. Capital Health s rapid access Neurovascular Clinic operates Monday through Friday to enable timely investigation and treatment of patients with suspected transient ischemic attack or mild stroke in order to reduce their risk of suffering a major stroke. The Monday clinic is held at the Cobequid Community Health Centre (CCHC), which many patients find easier to access than the Halifax Infirmary. The Vascular Neurology group continues to participate in weekly Neurovascular Case Conferences, in conjunction with Neurosurgery and Neuroradiology, to develop interdisciplinary management plans for patients with complex neurovascular problems. In addition, the Vascular Neurology group collaborates with the Connective Tissue Disease program, which is led by Dr. Gabrielle Horne in the Division of Cardiology. The division has, as well, community affiliated colleagues who need to be recognized for their commitment to outreach programs, even though they run very busy private offices affiliated with the division. In particular, Drs. R. Leckey and A. MacDougall conduct traveling clinics to Bridgewater, New Glasgow and Antigonish. More locally, Drs. R. McKelvey and J. Moeller also provide a very welcome consultative service to the Dartmouth General Hospital (DGH). New Programs, Partnerships and Innovations An Acute Stroke Protocol was implemented on April 1, 212, with the aim of treating more stroke patients sooner by coordinating the expertise of Emergency Health Services, the Departments of Emergency Medicine and Diagnostic Imaging, and the Division of Neurology. Following the implementation of this protocol, the median time from arrival in the Emergency Department to the administration of thrombolytic therapy dropped from 93 to 74 minutes. The Epilepsy Surgery Program has seen a remarkable increase in the complexity of patients being investigated that is commensurate with further maturation of the program and advances in local technology. A significant new strategy is the implantation of stereotactic EEG electrodes and enhanced use of FDG-PET scans to identify the seizure onset zone. The weekly Epilepsy Rounds, chaired and organized by Dr. Mark Sadler, continue with major patient management decisions made at case presentation rounds and literature reviews during Journal Club. There is excellent participation from all members of the adult and pediatric epilepsy groups. In order to address the current manpower shortage in Neurology, Dr. Richard Leckey obtained his Prince Edward Island (PEI) license in order to conduct clinics there on a monthly basis. This makes it much easier for PEI patients to be seen by a Neurologist in their home province and also the wait time was reduced. Efforts are being undertaken to recruit neurologic consultants for the province. Dr. Bernd Pohlmann-Eden developed the Halifax First Seizure Clinic (HFSC) which evolved to a full day outpatient clinic. Together with Karen Legg, NP, in the fall of 21 the whole process was redesigned and systematized. Major accomplishments have been achieved since then. Constant streamlining and optimizing of the service, regular weekly team meetings, careful triaging, and regular readjustment and revamping of clinic schedules, tracking DIVISION OF NEUROLOGY DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY 139

146 DIVISION OF NEUROLOGY all new referrals from receipt date and time to completion of triage processing time, became critical to allow new referrals to be seen within the targeted triage time. Dr. Bernd Pohlmann-Eden and Karen Legg, NP constantly offer extra clinic days to meet their ultimate goal that patients with first seizure will be assessed in a timely manner. A prospective database was further developed (maintained by Research Associate, Dr. Candice Crocker). This model of the First-Seizure Clinic has been recognized and acknowledged. Dr. Pohlmann-Eden received several invitations nationally and internationally to introduce this concept to other centers. Dr. Bernd Pohlmann-Eden and his team developed new assessment instruments for the Comorbidity Clinic to prescreen for anxiety, depression and cognition problems, which will be tested as a pilot study from 213 to 214. He is currently working on a new concept with the Head of Psychiatry, Dr. Nick Delva, as the Medical Liaison service is no longer able to cover the monthly Comorbidity Clinic. Together with Dr. Matthias Schmidt from Neuroradiology, he is continuing to cooperate with Dr. Andrea Bernasconi, from the Montreal Neurological Institute, with focus on post processing analysis of MRIs in-patients with epilepsy. He further developed a strong cooperation with Dr. Fernando Cendez in Campinos/Brazil. An application for the first Halifax-Havana course on temporal presentation lobe epilepsy surgery: Hermanos Ameijeiras Hospital Havana, Cuba April 9-13, 212 for an ILAE Visiting Professorship in Epileptology was successful in 211 with Dr. M. Sadler as the principal recipient. In Halifax, the Capital Health Epilepsy Program and Division of Neurosurgery agreed to provide additional support for 2 additional individuals (Susan Rahey & Dr. David Clarke) to develop and direct a comprehensive epilepsy surgery course in Havana. The overall objective of the course was to familiarize Cuban neurologists, neurosurgeons, and other health care professionals with the process of patient selection, interpretation of noninvasive investigations, and planning of temporal presentation lobe epilepsy (TLE) surgery. Work for the Nova Scotia Department of Health and Wellness The Capital Health Stroke Program is one of seven district stroke programs comprising the NS Stroke System. The program aims to implement, sustain, and monitor the Canadian Best Practice Recommendations for Stroke Care throughout Capital Health. The program is managed by Richard Braha, Manager of the Acquired Brain Injury Program, with assistance from Debbie Merrick, Stroke Project Officer, Wendy Simpkin, Stroke Navigator, and Christine Christian, Data Analyst. The physicians affiliated with the program are Drs. G. Gubitz and S. Phillips, Division of Neurology, and Dr. A. Mountain, Division of Physical Medicine and Rehabilitation. Dr. Phillips is a Clinical Advisor for Cardiovascular Health NS., which oversees the Provincial Stroke System. The Dalhousie Multiple Sclerosis Research Unit (DMSRU) has been caring for patients and families with multiple sclerosis (MS) for over 32 years. DMSRU is an integrated clinical care and research program within the Division of Neurology at Capital Health. Their mandate is to provide expert-level evidence-based clinical care, be a leader in-patient advocacy, conduct research, and provide educational opportunities (for patients, families, health care providers, and the general public) (C.A.R.E). The team of physicians, nurses, allied health care providers, and researchers work collaboratively in all areas of the program, thus enhancing the patient experience as well as creating a positive team environment. Currently, there are more than 4 patients registered at the DMSRU. In the past year the program has registered 23 patient visits representing 21 unique patients of which over 9% are from Nova Scotia. DMSRU is comprised of the Halifax and Sydney sites. The continued increase in patient population and patient visits is directly linked to the incidence/prevalence of MS in Nova Scotia and to the increasing needs of the MS population. In the past year therapeutic advances in the treatment of MS have been made. Fingolimod (Gilenya), the first oral disease modifying drug (DMD), was approved by Health Canada providing an effective therapeutic option for patients with relapsing MS who have tried and failed or demonstrated intolerance to first-line DMDs. The anti-jcv assay, for detection of JC virus in serum, was demonstrated to be effective in predicting risk of progressive multifocal leukoencephalopathy in patients on natalizumab (Tysabri) and was approved by regulatory agencies thus allowing individualized risk stratification for patients receiving this therapy. Finally, fampridine (Fampyra), the first drug approved to treat walking impairment, was approved in March 212. DMSRU continues to collaborate with researchers locally, nationally and internationally on research projects spanning a variety of research domains including epidemiology, quality of life, disease modifying and symptom therapies, health economics, and basic science. DMSRU was the recipient of a CIHR grant (Dr. Ruth Ann Marrie from Winnipeg is the PI) to study Co morbidities in MS. The program collaborates locally and regionally with researchers through the umbrella of the EndMS Atlantic Regional Research and Training Centre and nationally with the EndMS Network and nationally and internationally with researchers who are outside of the EndMS Network. Presently the program is collaborating in numerous industry funded studies as well as studies funded by CIHR, EndMS Network, and MS Society of Canada. The local DMSRU team includes: Dr. V. Bhan (Director); Drs. C. Maxner, R. McKelvey, A. MacDougall, R. Leckey, Dr. M. Maharaj (Sydney) and L. Shimon (Sydney), John Fisk (EndMS RRTC Director), Dr. T. Chisholm (Psychiatry), Dr. J. Hendricks (Psychology), Dr. C. Short (PM&R), T. Campbell, NP (Nurse Practitioner/Manager), M. Kehoe, RN, M. Nickerson, RN, K. M. Weaver, RN (Sydney), K. Sabourin and N. Gormley (Research Coordinators), K. Stadnyk and M. Petley (Database Support), C. Gray and S. Smith (Administrative Support), C. McCarron, SN4 (Research Assistant), L. Berrigan (Post-Doctoral presentation Fellow), and J. Reid (EndMS Coordinator). 14 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY

147 Quality & Patient Safety The Quality of Care Report for the Division of Neurology will be presented on October 9, 213. Neurology Morbidity and Mortality Summary: April 1, 212 March 31, 213 The M&M Committee (chaired by Dr. Gord Gubitz) meets on a monthly basis. Divisional Members are encouraged to attend, as are Resident Staff, Medical Students and Specialty Nurse Practitioners. Attendance is recorded. Minutes of the previous Rounds are reviewed, and any actions resulting from the previous minutes are discussed. Prior to each meeting, members of the Division are encouraged to submit specific morbidity and process of care issues to the Chair. These are reviewed in detail at the Round, and areas requiring specific action are identified and assigned. The minutes are circulated to the Division M&M Committee Members, and to the Department of Medicine Professional Appraisal Committee (PAC). In addition, the Inpatient Care Team meets on a monthly basis to discuss the day to day operation of the Acute Stroke Unit and when indicated, the General Neurology Service. Specific instances related to the quality and safety of patient care are discussed at this venue. These discussions are used to inform the M&M process, and to respond to suggestions brought forth at the M&M Rounds. The HFSC meets weekly for quality assurance (to constantly review referral process, waiting time, data bank and developing partnerships. Shadow Charts This subject was discussed regularly at Business Meetings throughout 212/13. The group as a whole cannot see how it is possible to eliminate shadow charts until there is better electronic chart implemented. The Division understands the issue of an enhanced EMR is being evaluated by Capital Health leadership. Further to the issue of shadow charts several division members have taken leadership in discussing ownership of charts with input from Capital Health, Canadian Medical Protective Association (CMPA), Doctors Nova Scotia, and the College of Physicians and Surgeons, Nova Scotia. At present the DMSRU clinic, as a first effort to eliminate paper records, are trying to utilize the Horizon Patient Folder (HPF) system to access documents online; this will be evaluated on its efficiency at the end of the 212/13. DIVISION OF NEUROLOGY Most of the persons who die do so while on the Stroke Unit these deaths are expected. Therefore, prior to each M&M meeting, the Chair reviews all mortality cases to ensure that all of the documentation has been appropriately completed. The Chair also determines whether there are specific issues arising from the deaths that are not expected during the palliative care process. These specific cases are then brought up for discussion at the Round. Relevant neuro-imaging studies are also reviewed. Minutes generated from the M&M rounds are prepared pursuant to the Evidence Act of NS. S. 6(2) and Freedom of Information and Protection of Privacy Act of NS. S. 19D (1) as amended. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY 141

148 DIVISION OF NEUROLOGY Average Length of Stay The Neurology care teams (stroke and general neurology) intensively review each patient daily to determine opportunities to expedite investigations, management, and discharge. This includes frequent comprehensive team meetings of all caregivers to have maximum input to review patient details. There are some systemic issues which have been identified as leading to delays in investigation such as missing test requisitions and constrained availability of technology, i.e. delays in obtaining MRI scans. As each of these issues are identified efforts are undertaken to remediate the problem. The service Chief (Dr. Maxner) meets with the 8.1 nursing administration team to review recent admissions and opportunities for discharge. This may culminate in Dr. Maxner contacting affiliated services requesting assistance in transferring patients off-service. Nonetheless, Alternate Level of Care (ALC) patients and patients awaiting transfer occupy a high percentage of bed resources for the division. For example, from March of 212 until March of 213 there has been escalation of ALC bed days from 146 to 53 per month. It is to be noted that nursing unit 8.1 has 3 beds and, thus, effectively 9 possible bed days per month. Thus, in the month of April 213 more than 5% of possible bed days were not available for acute patient care management. Public Education For each new patient seen in the HFSC by Dr. Bernd Pohlmann-Eden and Karen Legg, NP, a pamphlet is provided. This gives the patient information on the team members who will be involved in their care, what diagnostic steps may be included in their visit, what to do to prepare for their visit to the clinic and the plan on a go forward basis for each patient. Newly diagnosed patients seen through the DMSRU clinic receive an individualized comprehensive education session regarding MS and its potential therapies under the leadership of Mike Kehoe, RN. Issues of Appropriateness of Care Drs. Gubitz and Phillips consult with family members of stroke patients regarding the level of care that is appropriate. There is a designated room which is set up specifically for palliative care of 8.1 patients. If a consult comes through from the Emergency Department (ED), the Staff Neurologist on call will make the decision of whether the consult is appropriate or whether it should be referred to another service. Clinical Services Neurologists provide Emergency coverage, inpatient, ambulatory and neuro-diagnostic clinical services. Specialized neurological care for patients in Capital Health and tertiary care for the province including: Electroencephalography (EEG) Lab Electromyography (EMG) Lab Epilepsy Program Multiple Sclerosis Neuro-Ophthalmology Clinic Behavioral Neurology Clinic Neuromuscular Clinic Neuro-Oncology Clinic Neurovascular Clinic General Neurology Clinic Movement Disorder Clinic Huntington s Clinic Halifax First Seizure Clinic Emergency Coverage Neurologists provide 24 hour, 7-day emergency and on-call coverage for patients in the province. 142 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY

149 Inpatient Services 24 hour/day 7 day/week attending / on-call physician coverage provided to the 3 bed Neurology inpatient unit (HI 8.1) which includes Stroke and General Neurology patients. The average bed utilization for the year 212/13 was 29.8 beds compared to 28.9 in 211/12. Average bed utilization and occupancy rates are shown in the following graphs: Figure 1 The occupancy rate increased to 11.2% in the year 212/13. The number of admissions decreased in 212/13 to 69 compared to 737 in the year 211/12. The average length of stay (ALOS) has increased to 14.1 days in 212/13. Figure 2 Neurology Inpatient Bed Occupancy Rate by Fiscal Year 12% Capital Health s Discharge Abstract Database (DAD) shows that there were 748 cases cared for by Neurology services at the QEII Hospital in 211/12 with an Average Length of Stay (ALOS) of 15.4 days; Expected Length of Stay (ELOS) was 7.2 days. Conservable bed days were 6,152 days. However, on further analysis, only 532 of the 748 cases were considered typical. ALOS for typical patients was 7.9 days with an ELOS of 6.2 days. Conservable bed days for typical patients were 918. Therefore, 216 Atypical Patients accounted for 5,247 conservable bed days or an average of additional days per patient. DIVISION OF NEUROLOGY Neurology Average Bed Utilization by Fiscal Year 35 3 Percent Occupancy 1% 8% 6% 4% 89.1% 88.% 99.5% 98.1% 11.2% This would suggest that there is difficulty with the flow of ALC patients off the 8.1 floor. Additionally, there have been significant stresses on the rehabilitation program which has culminated in delays of patients being transferred from 8.1 to the Nova Scotia Rehabilitation Centre services. Beds 25 2% % (Note: The DAD uses different definitions related to where patients spend most of their stay, which explains why the number of cases differs slightly from the number of admissions, captured by the STAR database) Used Avail Figure 3 Figure 4 Neurology Inpatient Admissions by Fiscal Year 8 Alternate Level of Care Days Neurology (8.1) Service (Stroke & General) Admissions ALC Days April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY 143

150 DIVISION OF NEUROLOGY The average length of stay (ALOS) for Neurology Patients in the year 212/13 was 14.1 days. Figure 5 Neurology Inpatient Average Length of Stay (Days) by Fiscal Year Inpatient Consultations Inpatient consultation service is provided by neurologists to other services at the Halifax Infirmary and VG sites. 446 patients were seen in consultation which is a 4.7% increase over the previous year. Consultations have increased in acuity and complexity. Figure 6 Neurology Inpatient Consults # Consults Days Ambulatory Care Source: Manual Data Neurologists provided specialized neurological consultation for 7,22 outpatients in 212/13, including General Neurology patients and specialized clinics for Multiple Sclerosis, Neuromuscular, Neurovascular, Behavioral Neurology and Epilepsy, which is a 1.3% decrease from 211/ % of the visits were new patients whereas 75.6% were return patients. The presence of more specialized neurology clinics equates to higher return rates. An additional 697 patients were seen in Neuro- Ophthalmology and Neuro-Oncology clinics. There were an additional 1,191 chart checks performed in 2 not included in the following figures. Table 1 Clinic Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Neurology ,825 Behavioral Neuro Epilepsy ,185 Multiple Sclerosis ,633 Neuromuscular Neurovascular Subtotal ,22 Neuro Ophthal Neuro Oncology Subtotal Total , DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY

151 Figure 7 Neurology New and Return Ambulatory Care Registrations 8, Registrations 6, 4, Figure 9 General Neurology Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days 15 1 Figure 11 Geriatric Behavioural Clinic Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days 15 1 DIVISION OF NEUROLOGY 5 5 2, CodeMissing New 1,62 1,721 1,725 1,822 1,76 Return 4,397 4,833 4,618 5,212 5,179 Total 6,452 6,998 6,731 7,317 7,22 % New 25.1% 24.6% 25.6% 24.9% 24.4% Average Wait Time Standard Wait Time Count Minimum Wait 1 Maximum Wait % Within Standard 75% 77% 8% 74% 69% 65% 65% 75% Source: PHS Data Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 54% 56% 82% 65% 79% 87% 1% 97% Source: PHS Data Wait times for general neurology outpatient visits as well as subspecialty clinics are shown in the following graphs by triage category. Referrals to the General Neurology clinic and to the subspecialty clinics were all seen within the recommended standards. Figure 8 General Neurology Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Figure 1 Neurology Multiple Sclerosis Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 1% 97% 96% 1% 1% 1% 1% 88% Source: PHS Data Figure 12 Neuromuscular Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days 1 5 Average Wait Time Standard Wait Time Count 1 1 Minimum Wait 1 6 Maximum Wait 1 6 % Within Standard 1% % % 1% % Source: PHS Data Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 88% 84% 97% 94% 89% 89% 83% 1% Source: PHS Data DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY 145

152 DIVISION OF NEUROLOGY Figure 13 Neuromuscular Semi-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Figure 15 Neurology Epilepsy Semi-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days 4 2 Figure 17 Neurovascular Emergent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 81% 94% 92% 1% 1% % 67% 1% Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 1% 1% 1% 1% Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 67% 86% 1% 1% 1% % 1% 1% Source: PHS Data Source: PHS Data Source: PHS Data Figure 14 Figure 16 Figure 18 Neuromuscular Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 37% 5% 47% 43% 43% 46% 49% 48% Source: PHS Data Neurology Epilepsy Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 34% 4% 27% 45% 48% 55% 52% 76% Source: PHS Data Neurovascular Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days 1 5 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 88% 93% 1% 1% 1% 94% 1% 85% Source: PHS Data 146 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY

153 Figure 19 Neurovascular Semi-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 75% 1% 1% 1% 95% 74% 1% 1% Source: PHS Data Figure 2 Neuro-diagnostic Laboratories Staff in highly specialized neuro-diagnostic laboratories at the Halifax Infirmary Site performed 1,485 EEG and 2,34 EMG studies during the 212/13 fiscal year. The wait time for non-urgent outpatient EEGs was 3 weeks at the end of March 213. The wait time for non-urgent EMG studies decreased from 22 weeks in March 29 to 2.8 weeks in March 213. EEG volumes do not include video-eeg telemetry recordings which require significantly more technician and physician interpretation time. There were 361 Video Telemetry bed days. Figure 21 Figure 22 Electromyograms (EMG's) Performed 2,5 # EMG's 2, 1,5 1, In-patient Out-patient 1,871 1,56 1,42 2,35 2,183 Total 2,13 1,671 1,567 2,183 2,34 DIVISION OF NEUROLOGY Source: Manual Data Neurovascular Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 1% 99% 96% 1% 1% 1% 99% 1% Source: PHS Data Electroencephalograms (EEG's) Performed 2, # EEG's 1,6 1, In-patient Out-patient 1,6 1,194 1,116 1,25 1,186 Total 1,354 1,563 1,422 1,567 1,485 Source: Manual Data The wait time for EEG at the end of the fiscal year 212/13 was 3 weeks which is below the recommended standard. Figure 23 Out-Patient Wait Times for a Non-Urgent EEG # Weeks April M J J A S O N D J F M April M J J A S O N D J F M Average Wait Time Standard Wait Time Source: Manual/PHS Data DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY 147

154 DIVISION OF NEUROLOGY The wait time for a Non-urgent EMG study at the end of the fiscal year 212/13 was 2.8 weeks. Figure 24 Out-Patient Wait Times for a Non-Urgent EMG # Weeks April M J J A S O N D J F M April M J J A S O N D J F M Source: Manual/ PHS Data Patient Residency Distribution of patient residency is shown, with the majority of patients from the Capital District (88.6% of inpatients and 64.% of outpatients). This reflects the demographics of the province and supports the need for access to subspecialized neurology outpatient clinics. Figure 25 Neurology Inpatient Admissions Distribution of Patient Residency by Health District QEII Health Sciences Centre, Out of Province: 11 SWH: 9 SSH: 8 PCHA: 4 GASHA: 3 CHA: 1 CEHHA: 19 CBDHA: 2 AVDHA: 13 CDHA: 611 Figure 27 Neurology Average Wait Time - Consult Request to Admit Ordered Capital Health, Average Wait Time - Consult Request to Admit Ordered (hrs) Benchmark Volume Volume Source: EDIS *23-8 and 8-23 are based on consult request times. *Times included when the consulting service is also the admitting service Figure 26 Neurology Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, Out of Province: 343 SWH: 31 SSH: 344 PCHA: 225 GASHA: 144 CHA: 131 CDHA: 4,618 CEHHA: 554 CBDHA: 1 AVDHA: DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY

155 Education Neurologists provided approximately 373 hours of medical education to undergraduate and postgraduate trainees in 211/12. Undergraduate Medical Education Dr. Ian Grant continues to serve as Unit Head for the Neuroscience and Special Senses Unit in Undergraduate Medical Education. This unit, which is a major element of the Med II program, was developed for the renewed curriculum in 211 and continues to evolve and expand. Dr. Grant has also assumed responsibility for the Clinical Skills Program in Bedside Neurology Teaching for the Med II students, and this too is under revision to improve teaching of neurologic examination skills. Division members completed 8 hours as preceptors for Med I Rotating Electives, 52 hours of Med II Case-Based Learning (CBL): Foundations and Neurosciences, 255 hours as Tutors in the Med II Neuro Clinical Skills section in 212/13. Division members provided hours to Med 2 OSCE exams; and 5.5 hours to Med III OSCE exams in 212/13. Division members provided 18 hours of lectures to the Med II Wednesday afternoon seminars and Dr. Ian Grant presented a 2 hour refresher course on the Neuro exam to the IMU link students. Postgraduate Medical Education The Post Graduate Program under the leadership of Dr. Gord Gubitz once again was very active in conducting numerous education sessions for the residents as well as providing superb clinical training. The program was reviewed by the Royal College in February 212 and was noted to be an excellent program that required no major revisions and received full accreditation. 15 residents from the following programs rotated through the neurology service from July 1, 212 to June 3, 213: Ophthalmology Physical Medicine & Rehab DIVISION OF NEUROLOGY All neurologists contribute directly to undergraduate education by tutoring, lecturing, clinical demonstrations, evaluation, electives and course development. Psychiatry Anaesthesia 4.5 Med 1 & II elective rotations were completed in Neurology in 212/13, with the addition of 2, 2-week Pre- Med 3 IMU Hospital Experience Rotations. 19 four-week Med 3 rotations were completed in Neurology. Urology 26 Core Internal Medicine residents rotated through the neurology services in the 212/13 academic year. 38 two, three or four week Med 4 elective rotations were completed in Neurology in 212/13 including 26 by non- Dalhousie students. Neurologists presented 9 hours of lectures at Internal Medicine Academic Half Day in 212/13. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY 149

156 DIVISION OF NEUROLOGY Sub-specialty Medical Education The Dalhousie Adult Neurology Residency Training Program continues to attract top quality and highly sought after candidates in the CaRMS PGY1 match. Dr. Stephen Douglas and Dr. Ayoub Dakson joined the program as PGY1 residents in July 212, and Dr. James Mathers transferred from PM&R as a PGY2. Dr. Cory Jubenville completed his Royal College examinations in June of 213 and does not have an expressed interest to do further subspecialty training. He will be joining Dr. Roger McKelvey in community practice in Dartmouth, NS. Dr. Colin Josephson completed his Royal College examinations in June of 213. He will be going to Calgary for a two year program in epilepsy and according to Dr. Mark Sadler this can be custom designed to have him receive the training that will be needed by the next consultant in epilepsy at Dalhousie. Dr. Josephson will be starting in Calgary in July 213. Continuing Medical Education The division welcomed 8 visiting professors in 212/13, as follows: Dr. Elizabeth Loder, Associate Professor of Neurology, Harvard Medical School. MA, USA. Dr. Fernando Cendes, Neurologist, State University of Campinas, Dr. Rolando Del Maestro, Neurosurgeon, McGill University, Montreal, QC. Dr. Gavin Langlands, 5th year medical student, Aberdeen, Scotland. Dr. Wee Yong, PhD, Clinical Neursciences and Oncology, University of Calgary, Calgary, AB. Dr. Douglas J. Cook, Fellow in cerebrovascular neurosurgery, Stanford University, CA, USA. Dr. Bernd Pohlmann-Eden organized the 2 nd Halifax International Epilepsy Conference which took place at Oak Island, Halifax, NS on September 2-21, 212. World-class faculty from Europe, USA, Canada and Brazil attended. The topic was Pharmacoresistance in Epilepsy and the high-ranking journal EPILEPSIA agreed to publish all contributions. Halifax hosted the 43 rd Atlantic Clinical Neurosciences Conference and annual General Meeting in May 212 organized by Drs. Gord Gubitz and D. King. It was held at the Art Gallery of Nova Scotia. Division faculty presented 67 continuing medical education lectures at various local, national and international venues in 212/13. Division members recorded their attendance at 22 continuing medical education seminars or meetings in 212/13. Dr. Heather Rigby completed her Royal College examinations in June of 213. Heather and her family are moving to Arizona where she will be undertaking training in the area of movement disorders at the Mayo Clinic. Additionally, Dr. Rigby graduated from her Masters of Medical Education Studies in 212/13 and also published the research component of her Master s Program in the journal Neurology. Dr. Rami Burstein, Professor of Anesthesia and Neuroscience, Harvard Medical School, MA, USA, Dr. Francine Chassoux, Neurologist, Hospitalier Saint- Anne, Paris, France. Dr. Laine Greene is completing a Fellowship year in training in Tucson, AZ in basic science of pain and will be moving in July 213 for a year of clinical headache management with Dr. David Dodick at the Mayo Clinic. 15 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY

157 Research The Division generated $649,155 in research grants and $518,324 in industry contracts during 211/12 for a total of $1,167,479. Dr. S. Darvesh does research involved in medicinal chemistry, biochemistry, chemoarchitecture, and clinical aspects of Alzheimer s disease and related disorders. In 212/213 he published 8 papers in highly regarded journals. His work was presented at 11 National and International conferences. He holds 2 Capital Health grants, 1 Dalhousie Medical Research Foundation (DMRF) grant, 1 CIHR grant, 1 IWK Research Foundation Grant and 1 BRC grant. Dr. Darvesh continues as the Director of The Maritime Brain Tissue Bank. Dr. Donald Weaver leads an active programme focused on the design and development of new drugs for the treatment of Alzheimer s dementia (AD). Dr. Weaver is both a neurologist and a medicinal chemist, an extremely unique combination of skills ideally suited for the task of drug discovery. Dr. Weaver and collaborators have been working on the discovery of curative drugs for AD for more than 15 years. He is the co-discoverer of tramiprosate, the first curative drug for AD to have reached human clinical trials worldwide, being studied in more than 2, people in both the USA and Europe. At Dalhousie University, Dr. Weaver is working on designing drugs to prevent the toxic clumping of amyloid protein that is implicated in the cause of AD. This work is done using state of the art computer modeling methods coupled with innovative techniques for drug molecule development. This work has garnered international attention, being awarded the prestigious $1Million Centennial Prize for AD Research from the American Health Assistance Foundation in 27 and the Prix Galien Canada Research Award in 29. It has also resulted in numerous patents and in the founding of several biotech companies, such as Treventis Corp. The Neurovascular Research Group (Drs. Stephen Phillips. Gordon Gubitz, Gwynedd Picket, Division of Neurosurgery, and Jai Shankar, Division of Neuroradiology,) is participating in investigator-led acute treatment trials of ischemic and hemorrhagic stroke funded by the CIHR and NIH. Dr. Bernd Pohlmann-Eden is the Principal investigator of a randomized control trial of Lacosamide versus carbamazepine in new-onset epilepsy. He was awarded several educational grants from research agencies (e.g. NSHRF), Research facilities of Dalhousie University (eg. Brain Repair Center), and pharmaceutical companies (eg. UCB Pharma Canada) in order to perform the 2nd Halifax International Epilepsy Conference & Retreat on Pharmacoresistance in Epilepsy. Publications / presentations by division members in 212/13 included: 31 peer reviewed papers published 4 peer-reviewed book chapters published 33 abstracts were presented at national or international scientific meetings 7 abstracts were presented at local scientific meetings 4 resident or student supervised abstracts presented at national scientific meetings Administration Neurologists perform the following administrative activities: Division Head, including all responsibilities of the position. Service Chief and Deputy Service Chief duties for inpatient services. Division members act as Medical Directors for: Stroke and General Neurology Services General Inpatient Neurology Consultation Services EEG and EMG Laboratories Dalhousie MS Research Unit Neurovascular Clinic Epilepsy Clinic Epilepsy Transitional Clinic Halifax First Seizure Clinic Behavioral Neurology Clinic Movement Disorders Clinic Huntington s Disease Clinic Neuromuscular Clinic Neuro-ophthalmology Clinic Research Neurology Program Director (Neurology Subspecialty and Medicine Postgraduate and Undergraduate Education) DIVISION OF NEUROLOGY DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY 151

158 DIVISION OF NEUROLOGY Divisional members assume a leadership role in administration by participating in: Hospital committees Department committees University committees Affiliated local, regional, national and international organizations Division members provided referee or editorial services to 68 journals and 21 granting agencies in 212/ DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF NEUROLOGY

159 Division of Palliative Medicine DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PALLIATIVE MEDICINE 153

160 DIVISION OF PALLIATIVE MEDICINE Division Highlights Dr. David Dupere, Associate Professor in the Faculty of Medicine. He is program director for Palliative Medicine Residency Program. Dr. Jeff Dempster, Associate Professor in the Faculty of Medicine. He has assumed a lead role on quality initiatives for the Division and also sits on the residency program committee. Dr. Robert Horton, Associate Professor in Faculty of Medicine is leading a major initiative in developing a public-private partnership for the creation of an inpatient Hospice and Center of Excellence in Capital Health. Dr. Kenneth Johnson is a Co-Chair of the Capital Health Research Ethics Board. Dr. Paul McIntyre, Division Head of Palliative Medicine. Postgraduate trainees: Dr. Danielle Kain and Dr. Erin Gorman-Corsten. A Fond Farewell to Dr. Liana Aires Capital Health Integrated Palliative Care Service (CHIPCS) Continuing care has devolved to the district, designating three community coordinators for palliative care. In conjunction, the QEII-based Palliative Care Consult teams have committed to a service model aimed at building capacity for palliation beyond the current geographic and clinical referral bases. The Nova Scotia Department of Health and Wellness initiated a program for funding essential medications for palliative patients registered with the district service. Physicians provide 24 hour, seven day/week emergency and on call coverage for the Capital Health Integrated Palliative Care Service (CHIPCS).This includes patients in the community and in hospital. Attending service coverage is provided for a 13 bed inpatient unit (1 beds on 7A and 3 beds on 5A at the VG Site). Inpatient consultation service is provided at the HI, VG, VMB, Abbie J. Lane, NSRC and Dartmouth General Hospital. Outpatient clinics are held at the Nova Scotia Cancer Centre and the Cobequid Multi-Service Centre. Palliative Medicine physicians provide daily home consult service to patients/families in the home setting. Palliative Medicine provided one day per week clinical Palliative Care service to patients in West Hants. Physician Resources There are 6 palliative medicine physicians (5. FTE s); 3 full time and 3 part time. New Programs, Partnerships & Innovations Capital Health Integrated Palliative Care has joined with the Hospice Society of Greater Halifax and Metro Rotary Clubs to support the development of a 1-bed Hospice Centre of Excellence. In affiliation with CHIPCS and Dalhousie Medical School, Rotary House Residential Hospice Centre of Excellence will provide state of the art hospice and palliative care as well as leadership in medical education and research. Capital Health has committed $8, in annual funding in order to support and sustain operation of Nova Scotia s first residential hospice. This commitment also includes closing 5 of our 13 tertiary level palliative care beds. In addition to financial resources, Capital Health will provide administrative resources towards the establishment of operational policies, standards and guidelines for residential hospice services and clinical expertise from CHIPCS. Dr. Dempster is chairing a working group that is overseeing re-organization of Palliative Medicine clinical services. The new service model is focused on improving access to community based palliative care teams and will improve continuity of care and decrease care transitions within the palliative care program. The new model is scheduled to launch in January 214. Dr. McIntyre was lead author on a proposal to Capital District Health Association/QEII Foundation to create an endowed research chair in Palliative Care. 154 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PALLIATIVE MEDICINE

161 Work for the Nova Scotia Department of Health and Wellness Dr. McIntyre sat on the Department of Health and Wellness Palliative Care Steering Committee which created a Provincial Framework on Hospice Palliative Care for presentation to the Deputy Minister of Health. Quality Patient Safety Dr. Dempster and Dr. Horton undertook a survey of family of descendants looking at disposal of medications after death. As a result of this, a fact sheet on medication disposal was developed. It is now being used to educate patients and their families on safe disposal practices, particularly opioid medications. This is being used throughout the CHIPCS program and includes VON services. Issues of Appropriateness of Care Dr. Horton sits on a Department of Medicine working group that aims to improve quality of care and coordination of clinical services provided to frail patients with complex illness/multi-morbidity Dr. Horton was the Division lead in a Capital Health community based partnership that oversaw the successful development of an operational funding plan for the establishment of a Residential Hospice Centre of Excellence in Capital Health. Establishment of Nova Scotia s first residential hospice facility will improve access to quality end-of-life care and give patients options other than hospitalization at the end-of-life. Clinical Services New Consults: Figure 1 Palliative Care Patients Initially Seen by Site Capital Health, ,2 1, Other 1 PCU LTC Tri-Facilities HCH DGH NSCC QEII Home Total 1,128 1,117 1,119 1,25 1,38 Source: ZIM/Casper Data Consults There were 1,38 new consults to the service in 212/13. DIVISION OF PALLIATIVE MEDICINE DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PALLIATIVE MEDICINE 155

162 DIVISION OF PALLIATIVE MEDICINE Inpatient Consults: Figure 2 Palliative Care, Inpatient Consults Capital Health, Consults DGH HI VG Total Source: ZIM/Casper Data There were 528 new consults at the VG, HI and Dartmouth sites in 212/13. Figure 4 Primary Diagnosis of New Patients Capital Health, % % of Patients 9% 8% 7% 6% 5% 4% 3% 2% 1% % Missing Diagnosis Non-Cancer Cancer Total 1,125 1,117 1,119 1,25 1,27 Source: ZIM/Casper Data Figure 4 identifies the percentage and volume of new patients to the Palliative Service whose primary diagnosis is a cancer vs. non-cancer diagnosis. New Consults by Gender: Figure 6 Palliative Care New Consults by Gender Capital Health, Consults Female Male Total 1,125 1,117 1,118 1,25 1,27 Source: ZIM/Casper Data Figure 3 New Consults by Age: Palliative Care, Inpatient Consults Average Daily Census Capital Health, Figure 5 Palliative Care New Consults by Age Group Capital Health, ,2 # Patients Consults 1, DGH HI PCU VG Other Source: ZIM/Casper Data Total 1,125 1,117 1,118 1,25 1,27 Source: ZIM/Casper Data ` 156 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PALLIATIVE MEDICINE

163 New Consults by Postal Code: Figure 7 lists patients who reside in Urban Halifax broken down by patient s forward sorting address. (The forward sorting address describes the area in the urban region. The last 3 digits denote the street the patient resides). The table and map include patients who reside in Halifax, Dartmouth, Bedford, and Sackville area. Figure Rural Total DIVISION OF PALLIATIVE MEDICINE DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PALLIATIVE MEDICINE 157

164 DIVISION OF PALLIATIVE MEDICINE Wait Time by Triage Category: The following urgent and non-urgent average wait times are recorded in the Palliative Service database. These new patient consults include inpatient (the majority) and outpatient consults. If a patient has been seen as an inpatient and then as an outpatient in the NSCC clinic the patient is not recorded as a new outpatient consult but as a return visit. Figure 8 Palliative Care Urgent New Patient Consults Average Wait Time (Days) by Quarter Capital Health, Figure 1 Palliative Care Urgent Distribution of Wait Times Capital Health, Patients <= Patients Cumulative % 87.% 91.3% 91.9% 93.2% 93.2% 96.9% 97.5% 1.% Source: Casper Data Wait Time (Days) 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % Cumulative Percent Figure 12 Palliative Care Deaths by Location Capital Health, ,2 # of Deaths 1, Long Term Care Hospital Pall Care Unit Home Total 1, , Source: Casper Data Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 83% 93% 88% 9% 83% 96% 89% 84% Source: ZIM/Casper Data Figure 9 Palliative Care Non-Urgent New Patient Consults Average Wait Time (Days) by Quarter Capital Health, Days Figure 11 Palliative Care Non-Urgent Distribution of Wait Times Capital Health, Patients % % <= Patients Cumulative % 65.4% 72.7% 78.6% 82.9% 85.9% 88.1% 89.8% 94.7% 1.% Wait Time (Days) Source: Casper Data 9% 8% 7% 6% 5% 4% 3% 2% 1% Cumulative Percent There were 83 deaths recorded, by location of death, in 212/13. This data includes all patients referred to the Capital Health Integrated Palliative Care Service. Figure 13 Palliative Care Distribution of Length of Stay from Program Entry to Death Capital Health, Total = Participants Source: ZIM/Casper Data 1% 9% 8% 7% 6% 5% 4% 3% % % Days > 599 % Cumulative Percent Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 9% 87% 85% 88% 9% 89% 91% 9% 63% of the participants in the program have died within 49 days of enrollment. 29% of participants remained in the program for less than 9 days. Source: ZIM/Casper Data 158 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PALLIATIVE MEDICINE

165 Figure 14 Palliative Care Median Days from Program Entry to Death Capital Health, Days by shifting care of dying patients to a more appropriate setting. Figure 16 Palliative Care Percent of Deaths by Location Capital Health, % Percent 9% 8% 7% 6% 5% 4% Home Consult Service: Figure 18 Palliative Care Physician Home Visit Registrations Capital Health, # Registrations DIVISION OF PALLIATIVE MEDICINE Median (Days) Average (Days) Deaths Source: ZIM/Casper Data Figure 15 Percent Patients in Home Component Who Died At Home Capital Health, % % Patients 5% 4% 3% 2% 51.9% 44.8% 43.9% 56.2% 51.5% 3% 2% 1% % Long Term Care.9% 1.2%.6%.%.% Pall Care Unit 21.4% 22.4% 24.2% 25.% 27.% Home 29.% 26.4% 28.1% 32.5% 3.4% Hospital 48.8% 5.1% 47.% 42.5% 42.7% Total 1.% 1.% 1.% 1.% 1.% Source: Casper Data Figure 17 Palliative Care Percent of Time Spent by Location of Death Capital Health, % Percent 9% 8% 7% 6% 5% Figure 19 Palliative Care: Home & Phone Visits By RN Capital Health (excluding Hants & Tri-Facilities) , Registrations 1, 8, 6, 1% % Source: Casper Data Figure 15 outlines the percentage of patients dying at home of those who have been seen at least once by a Palliative Medicine home team. Capital Health Integrated Palliative Care Service devotes significant resources to caring for patients in their homes. The rate of home death is double the provincial average. The public private partnership to create a Hospice Centre of Excellence is designed to create capacity in acute care 4% 3% 2% 1% % Home Hospital LTC PCU PCU.2%.1% 3.5% 7.1% LTC.5%.% 83.7%.% Hospital 9.5% 78.8% 3.% 58.3% Home 89.7% 21.% 9.8% 34.6% Total 1.% 1.% 1.% 1.% Source: Casper Data Figure 17 measures the percent of time spent by palliative service patients at home, PCU, Hospital, LTC or as discharged patients (not being followed by the service) from the time they are admitted to the service to their death (by place of death). The majority of patient days were at home. 4, 2, Phone 7,618 7,51 6,718 5,77 4,978 Home 2,589 2,452 2,399 1,634 1,738 Total 1,27 9,962 9,117 7,341 6,716 Source: Manual & STAR Data There were 1,738 Home Visits registered at Capital Health in 212/13. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PALLIATIVE MEDICINE 159

166 DIVISION OF PALLIATIVE MEDICINE Figure 2 Palliative Care RN Registrations Hants Community Hospital, Registrations NSCC Ambulatory Registrations: There were an additional 58 chart checks performed in 212/13 not reported in the following figure. Figure 22 CHIPCS Outpatient Clinic Component NSCC Ambulatory Registrations 1, 8 Inpatient Services Figure 23 CHIPCS Inpatient Unit Admissions VG Site, 3 Patients Clinic Phone Home Total Registrations An integrated Palliative Care Home Consult Service is available in the Hants Community. This program operates in collaboration with the QEII service and community physicians with nursing coordination and volunteer support. There were 471 RN registrations in 212/13. Figure New Return Total Source: OPIS Data Admit Emerg Admit Home Total There are 13 Palliative Care inpatient beds located on 7A (1 beds) and on 5A (3 beds) at the VG site. There were 219 admissions. 6% of admissions were from home. Figure 24 Palliative Care Home Consult Component Average Daily Census Capital Health, CHIPCS Inpatient Unit Percent of Inpatient Admissions by Source VG Site, 1% 9% 8% 7% # Patients 8 6 Percent 6% 5% 4% 4 3% 2% 2 1% Source: Casper Data % Emergency 33.5% 4.4% 41.1% 42.7% 42.% Home 66.% 58.8% 58.6% 57.3% 58.% Total 1.% 1.% 1.% 1.% 1.% The graph above does not include transfers from other units within the QEII. 16 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PALLIATIVE MEDICINE

167 Figure 25 CHIPCS Inpatient Unit Inpatient Average Length of Stay (Days) by Fiscal Year VG Site, 25 Days Figure 27 CHIPCS Inpatient Unit Percent Distribution of Inpatient Length of Stay VG Site, 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % More than 14 days 41.2% 37.3% 34.8% 38.4% 4.3% 8-14 days 18.% 16.6% 2.% 17.5% 15.5% - 7 days 4.8% 46.1% 45.2% 44.1% 44.1% Total 1.% 1.% 1.% 1.% 1.% Percent Figure 29 CHIPCS Inpatient Unit Bed Day Utilization by Fiscal Year VG Site, 6, Bed Days 5, 4, 3, 2, 1, Total Used 4,476 4,43 4,4 4,84 4,488 Avail 4,625 4,568 4,52 4,718 4,635 DIVISION OF PALLIATIVE MEDICINE Figure 26 Figure 28 Figure 3 CHIPCS Inpatient Unit Distribution of Inpatient Length of Stay VG Site, 35 CHIPCS Inpatient Unit Percent of Inpatient Separations by Type VG Site, 1% CHIPCS Inpatient Admissions Summary Distribution of Patient Residency by Health District QEII Health Sciences Centre, % 8% 7% Out of Province: 1 Non Capital District: 2 Patients Percent 6% 5% 4% 3% 5 2% More than 14 days days days Total % % Discharged 18.4% 28.5% 17.2% 13.7% 18.6% Died 81.6% 71.5% 82.8% 86.3% 81.4% Total 1.% 1.% 1.% 1.% 1.% Capital District: 216 The majority of inpatients to the service in 212/13 were residents of the Capital District. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PALLIATIVE MEDICINE 161

168 DIVISION OF PALLIATIVE MEDICINE Figure 31 Palliative Medicine Average Wait Time - Consult Request to Admit Ordered Capital Health, Average Wait Time - Consult Request to Admit Ordered (hrs) Benchmark Volume Volume *23-8 and 8-23 are based on consult request times. *Times included when the consulting service is also the admitting service Source: EDIS Data Education Dr. Horton created and implemented a palliative medicine case for the undergraduate medicine case-based learning Integration Unit. The Division continues a strong commitment to the medical teaching of undergraduates and postgraduates and the continued medical education of allied health professionals in a variety of settings. From July 1, 212- June 3, 213 a total 49 learners rotated through the Palliative Medicine service consisting of 13 Undergraduate and 34 Postgraduate students. The Palliative Medicine Residency Program jointly accredited by the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada and led by Residency Program Director, Dr. David Dupere, the Dalhousie Faculty of Medicine postgraduate Year of Added Competence in Palliative Medicine received full approval from the survey team during the accreditation process in 212. Dr. Keith Short completed postgraduate training in Palliative Medicine in June 212. Dr. Danielle Kain will complete her training on April 15, 213. Palliative Medicine physicians were active in the provision of continuing medical education, with 22 sessions presented during 212/13 to general practitioners, specialists and other trainees. Research There were 6 peer reviewed papers/book chapters/editorials in by physicians in 212/13. There were 3 national/ international and 1 local research presentations presented in 212/13. Physicians provided referee and editorial services to 1 journals. Administration Division Members Act as Directors/Chairs for: Division Head Service Chief duties for the Capital Health Integrated Palliative Care service Program Director, Undergraduate Program and the Postgraduate Residency Program. Program Director, Palliative Medicine Residency Program Committee Executive/Divisional Chiefs Committee Co-Chair, CHIPCS Steering Committee Chair, Quality, Morbidity and Mortality Sub- Committee Co-chair, Regional Taskforce Meeting, Breaking Barriers in Breakthrough Pain Chair, Palliative Care Committee, CDHA Care By Design Co-chair, Capital Health Research Ethics Board Chair, CHIPCS Clinical Service Working Group Co-Director, CHIPCS Consult Service Director, CHIPCS Home Service 162 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PALLIATIVE MEDICINE

169 Division of Physical Medicine & Rehabilitation DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION 163

170 DIVISION OF PHYSICAL MEDICINE & REHABILITATION Physician Resources Our Division physician complement is slightly decreased at 6.13 (decreased from 6.15) Full Time Equivalents (FTE) with 3.6 clinical FTEs. We had a physician on maternity leave from April of 212 to April of 213. In the rehabilitation program we collaborate with 2 hospitalists and a clinical assistant who help on the inpatient units, a nurse practitioner affiliated with our acquired brain injury program (stroke and brain injury) and 6 residents in our training program. We have 3 administrative assistants and two rehabilitation assessors who help in the running or the consult services for rehabilitation. We continue to work daily with allied health services and nursing in the rehabilitation programs in order to provide state of the art care for our patients. Our Patient Care We continue to provide inpatient, outpatient and outreach services to the province of Nova Scotia. We extend our expertise to PEI, NB and NL when needed. We provide secondary and tertiary level rehabilitation to a multitude of diagnosis including, but not limited to, persons with stroke, traumatic brain injury, neurodegenerative disorders, neuromuscular disorders, Multiple Sclerosis, Cerebral Palsy, traumatic and non-traumatic spinal cord injury, arthritis, polytrauma, deconditionning, chronic pain and amputation. This year our 6 bed, inpatient rehabilitation centre received permanent funding from Capital health to open 6 additional beds due to patient demands on our services and patient flow needs from the acute sites. We provided over 5 inpatient consults to the acute sites at Capital Health and transferred in 58 admissions from capital health (approx. 5%), other regional hospitals and the community. We provided 21,765 inpatient care days to our patients. We continue outpatient clinics in amputee management, musculoskeletal medicine, Multiple Sclerosis (MS), Stroke, Brain Injury, neuromuscular disorders and neurologic diseases, spinal cord injury, spasticity management and electromyography. We continue to provide interdisciplinary, combine clinics with neurology in management of Amyotrophic Lateral Sclerosis (ALS) and Spina Bifida (with urology and neurosurgery). This year pediatric transition clinics with the IWK. We continue to partner with neurology in the management of people with Multiple Sclerosis and with Digestive Care & Endoscopy in the management of people with neurogenic bowel. We have started an interdisciplinary orthotic (bracing) clinic to address an unmet need for patients with complex bracing needs in the community. We provided 76 telehealth visits to our patients that can t travel to the HRM for assessment and follow up care. We continue an outreach clinic at the Cobequid Community Health Centre and we piloted nursing home and home visits for our most mobility challenged patients. There were 3,712 outpatient clinics visits at the rehabilitation centre and Cobequid Community Centre sites in this fiscal year. 164 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION

171 New Programs, Partnerships & Innovations Dr. Saric has continued to develop the framework for a spasticity management program within the rehabilitation program at Capital Health. Spasticity is a complex medical condition that affects people with many different neurologic diseases. It can have profound negative effects on function and quality of life and has many negative consequences including skin breakdown, pain, contracture and care giver burden. The literature supports that an interdisciplinary approach to spasticity management is beneficial to patients with this condition. Dr. Saric has received external funding to hire a program developer for the next year to help us move toward our goal of having a coordinated interdisciplinary spasticity management clinic by the end of the year. This year Dr. Mountain started pediatric to adult transition clinics in Cerebral Palsy with the IWK. As children with chronic diseases reach their adult years it is very important to have a smooth organized approach to transition them into the adult medical world. Support systems can change drastically during this time as well as their needs for treatment and education. Dr. Mountain and the team in the neuro-rehabilitation clinic have partnered with the Cerebral Palsy management team at the IWK to help make this transition easier. In the transition clinic both the IWK and Rehab teams or key members of both teams are present at the first visit in the adult clinic. Then as the individual is seen for repeat visits the support from the pediatric clinic is slowly weaned away. This has led to strong therapeutic relationships with the new clinic team and smooth transfers of care. In our fiscal year our inpatient units were realigned into programmatic models to better focus specialty care for our different patient populations. This resulted in 3 main inpatient programs: Acquired Brain Injury (ABI) which includes our stroke and brain injury patients, musculoskeletal and amputee and neurorehabilitation and spinal cord injury. To continue with this evolution of our patient care models we launched our subspecialty consult services in November of 212. The subspecialty consult services mirror the patient populations in our inpatient programs. This has allowed more specialized consult services on the acute site, initiation of education and early rehabilitation on inpatients waiting for transfer to our facility and the building of stronger relationships with our acute care partners. As an example our neuro-rehabilitation and spinal cord injury consult service has developed a stronger patient care relationship with our neurosurgery group and now meet once weekly to do a combine rounds to review all of the spinal cord injury patients on the neurosurgery services. As a result new spinal cord injury patients are being consulted earlier (now in the ICU) and followed more closely during their acute inpatient stay. There is increased awareness and education on SCI specific issues and we are planning some quality of care initiatives to see if this is decreasing common complications or facilitating patient flow. One of the projects is a pre printed order to facilitate the management of neurogenic bowel after SCI on the neurosurgical service. With greater collaboration between the rehabilitation and neurosurgery group we have had the opportunity to participate in the development of standards for hospital accreditation for the treatment of persons with spinal cord injury with Accreditation Canada. Both our acute and rehabilitation sites participated in a mock accreditation in May of 212 as part of the process to finalize the accreditation standards with Accreditation Canada. This allowed us to evaluate our patient care and develop projects to improve patient care including clinical care pathways for both acute and rehabilitation management of persons with spinal cord injury. The SCI accreditation standards were published in January of 213 and will become part of accreditation for all hospitals providing acute and rehabilitation care for persons with spinal cord injury. In this fiscal year we developed an interdisciplinary clinic to address patients with complex needs for bracing and orthotics. This was done within existing manpower with no additional funds. This clinic receives referrals from specialists and primary care for patients with specialized bracing needs. In the 2 year we identified a need in our community for home and nursing home visits for our more disabled patients. Many of our patients have severe mobility disabilities that make getting to an outpatient visit expensive and sometimes near impossible leading to missed clinic visits and suboptimal care. Dr. Short and one of our clinic nurses (Roberta Maclean) started a pilot this year which provides nursing home visits and home visits to these individuals. Since beginning, we are now following 12 patients in the community at their homes or nursing homes with plans to expand this service in the year. We have began to receive referrals for nursing home visits direct from primary care physicians and the visits to the nursing homes have provided an opportunity to liaise with the nursing home teams and optimize care through education on the management of these often complex patients. A patient satisfaction questionnaire is planned for the year. DIVISION OF PHYSICAL MEDICINE & REHABILITATION DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION 165

172 DIVISION OF PHYSICAL MEDICINE & REHABILITATION Work for the Nova Scotia Department of Health and Wellness Dr. Mountain continues in her role as the division s physician representative for the Nova Scotia Stroke Strategy initiative. Dr. Short participated through the executive of the DOM in information gathering for the provincial physician manpower plan. Quality Patient Safety Rehabilitation team members continue to participate in rehabilitation program M and M rounds 3 times yearly. Safety and quality care is reviewed using case based examples. Following the team discussions, recommendations for improving patient care and safety are made. Quality and safety rounds are conducted on each of the inpatient units during the year with recommendations made to improve space and quality. Requests for funding through Capital Health to implement the recommendations on each unit have been made. Dr. Joyce and Mountain are representatives on our rehabilitation quality committee. Dr. Short sits on our building emergency/safety committee. We continue to use the Morse falls risk scale on all of our inpatients and the Bradden scale for risk of skin breakdown. We provide regular feedback to our teams and physicians on transmission rates for VRE and MRSA of which we are proud to have one of the lowest rates in the hospital. We also give regular feed back through capital health data on practices such as hand hygiene. We have had a steady increase in our hand hygiene. Our neurorehabilitation program participated in a national environmental scanning project for spinal cord injury rehabilitation services across Canada (ESCAN). The project began in 2 year and concluded in the 2 fiscal year with the publication of, Environmental Scan Atlas: Capturing Capacity in Canadian SCI Rehabilitation. C Craven, M Verrier, C Balioussis, D Wolfe, J Hsieh, V Noonan, A Rasheed, E Cherban, Rick Hansen Institute, ON, Canada 212. Dr. Short and Dr. Kirby were contributing authors to this book; and our Rehabilitation Centre was recognized as a centre of excellence in Canada for the management of neuropathic pain and for wheelchair skills training for persons with SCI. Average Length of Stay Our average length of stay this year was 47.2 days. This is increased compared to previous years and was felt due to a number of factors. If we look at the programs separately the LOS for our Stroke and Acquired Brain Injury unit is down at 46.5 days. The range for LOS for this unit over the last 5 years has been days, so this unit is at its lowest LOS in five years. This is likely due to the increase in bed numbers on this unit to 23 beds over the last 2 years to accommodate the need for our stroke populations and due to the introduction of a well functioning outreach and day program that started just over two years ago for this patient population. The outreach program has allowed earlier transitions to home of many of our brain injury patients. Both the Neuro/SCI and Musculoskeletal/amputee inpatient programs are showing longer length of stays for this fiscal at 47.6 days. This compares to average lengths of stays for those two programs of and 43.1 days over the last five years respectively. One factor we feel has contributed to this increased length of stay was the closing of our therapeutic pool which occurred in Dec 211. This was done due to safety and budgetary restraints. It has had a huge impact on patient care. The highest users of the pool were the patients in these two programs. For patients suffering from poly trauma and neurologic disorders the pool was used as a safe and effective tool for early remobilization. It takes more time and manpower causing inefficiency to remobilize these patients over ground. The timing of the closing of the pool matches with the increasing length of stays on both of these units. The pool has also been a critical tool to remobilizing bariatric patients who are a specialized population dealt with on both of these units. In addition to the pool closure, we have also had higher number of ALC patient days in the 2 year than in previous years and continue to identify limited supports in the community as a significant contributor to increased length of stays. Some of our units we are beginning to track more closely factors that contribute to extended length of stay such as delays in equipment, lack of continued therapy in home areas and delays in getting home supports (e.g. HCNS) into a home, funding delays 166 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION

173 for equipment and renovations at home etc. We hope by monitoring these factors more closely we may be able to identify the top factors that lead to delays in discharge and develop strategies to deal with these. Public Education Our rehabilitation program has started a respiratory hygiene education program. Many individuals with neurologic disorders will have compromise in their breathing function. This can contribute to morbidity and mortality and good maintenance of respiratory health can decrease complications. This program is a group based program for persons with neurologic disease and their families. It runs every 6 weeks at the rehabilitation centre and is broadcasted across the province via telehealth. Patients, their families and regional allied health (mostly Physiotherapy) attend these sessions to learn how to maximize respiratory health. Dr. Saric has provided public education through our local stroke clubs and Dr. Short has provided public education on mobility in Multiple Sclerosis through the Multiple Sclerosis Society. Issues of Appropriateness of Care The division and rehabilitation program continue to partake in the national rehabilitation reporting system through the Canadian Institute of Health Information. This data is used to compare our centre to our peers across the country in areas including length of stay and effectiveness of care. This information is reported back to our teams through the rehabilitation quality committee. We used this data in this fiscal year to realign our bed numbers on each of our units to allow timely access to rehabilitation services. We discuss appropriateness of care at our M and M rounds and we have an accessible rehabilitation committee, which Dr. Short sits on, who address access to rehabilitation services and appropriateness of care issues. Emergency Coverage Physicians provide 24 hour, 7-day emergency and on-call coverage for the rehabilitation inpatient service and telephone consultation to physicians throughout the Atlantic Provinces. Clinical Services The clinical responsibilities of the division s physician members include the following ambulatory and inpatient services: Inpatient Units Inpatient Consultative Service Emergency coverage Stroke Clinic Acquired brain Injury Outreach Program Multiple Sclerosis Clinic Spinal Cord Injury Clinic (including adult spinabifida) Acquired Brain Injury Clinic Electromyography (EMG) / Nerve Conduction Velocity (NCV) Clinic Neuromuscular Clinic DIVISION OF PHYSICAL MEDICINE & REHABILITATION Amputee Clinic Musculoskeletal / Trauma Clinic Spasticity management Clinic DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION 167

174 DIVISION OF PHYSICAL MEDICINE & REHABILITATION Inpatient Services There are 3 inpatient units located at the Nova Scotia Rehabilitation Centre (NSRC) with a bed capacity of 66 beds. Table 1 Unit/Designation * # Beds 212/13 5RC (Neuro rehab) 21 7RC (Acquired Brain Injury) 24 8RC (Musculoskeletal) 21 Total 66 * Number of beds available when there are no holiday or staff shortage reductions Figure 1 Physical Medicine and Rehabilitation 5th Floor Rehab Centre Inpatient Admissions and Transfers In by Fiscal Year 25 Admissions and Transfers Transfer In Admissions Total Figure 3 Physical Medicine and Rehabilitation 5th Floor Rehab Centre Occupancy Rate by Fiscal Year Percent 1% 8% 6% 4% 2% 98.9% 99.1% 96.6% 96.9% 96.7% % Occupancy Rate Max Target Neuro Rehab (5 th Floor) Figure 2 Figure 4 The 5 th Floor has 21 open beds although they have capacity to open beds in other rooms to accommodate special circumstances such as MRSA infection. Usually a bed in a double room is closed when a bed outside designated rooms is opened. Physical Medicine and Rehabilitation 5th Floor Rehab Centre Average Stay (Days) by Fiscal Year Physical Medicine and Rehabilitation 5th Floor Rehab Centre Bed Day Utilization by Fiscal Year 8, 6, Days 3 Bed Days 4, 2 2, Bed Days Unused Bed Days Used 7,119 5,758 7,232 6,468 6,73 Avail 7,196 5,813 7,491 6,678 6, DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION

175 Acquired Brain Injury (7 th Floor) The 7 th Floor has 24 open beds although they have capacity to open beds in other rooms to accommodate special circumstances. Figure 5 Physical Medicine and Rehabilitation 7th Floor Rehab Centre Inpatient Admissions and Transfers In by Fiscal Year 2 Admissions and Transfers Figure 7 Physical Medicine and Rehabilitation 7th Floor Rehab Centre Inpatient Bed Occupancy Rate by Fiscal Year Percent Occupancy 1% 8% 6% 4% 2% 98.5% 99.2% 99.1% 99.2% 97.4% % Occupancy Max Target Figure 8 Musculoskeletal (8 th Floor) The 8 th Floor has 21 open beds although they have capacity to open beds in other rooms to accommodate special circumstances. The 8th Floor was closed over the summer which is shown in the graph below by the low number of beds available. Figure 9 Physical Medicine and Rehabilitation Centre 8th Floor Rehab Centre Inpatient Admissions and Transfers In by Fiscal Year 3 Admissions and Transfers DIVISION OF PHYSICAL MEDICINE & REHABILITATION Tranfers In Admits Total Figure 6 Physical Medicine and Rehabilitation Centre 7th Floor Rehab Centre Bed Day Utilization by Fiscal Year 1, 8, Tranfers In Admits Total Physical Medicine and Rehabilitation 7th Floor Rehab Centre Inpatient Average Length of Stay (Days) by Fiscal Year 6 Days Bed Days 6, 4, 2, Bed Days Unused Bed Days Used 7,356 7,81 8,15 8,294 8,424 Available 7,469 7,141 8,182 8,358 8,649 Figure 1 Physical Medicine and Rehabilitation Centre 8th Floor Rehab Centre Inpatient Average Length of Stay (Days) by Fiscal Year Days DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION 169

176 DIVISION OF PHYSICAL MEDICINE & REHABILITATION Figure 11 Physical Medicine and Rehabilitation Centre 8th Floor Rehab Centre Inpatient Bed Occupancy Rate by Fiscal Year Percent Occupancy 1% 8% 6% 4% 2% 91.5% 93.7% 97.1% 99.3% 98.2% % Occupancy Max Target Figure 12 Inpatient Consultations Physicians provide inpatient consultation service at the NSRC, Halifax Infirmary and VG sites. Figure 13 Physical Medicine and Rehabilitation Inpatient Consults 6 Patients Figure 14 Physical Medicine & Rehabilitation Inpatient Consult Average Wait by Service 175 # of Consults AMPS Gen Neuro Consult MSK SCI Stroke TBI Sub- ALC Acute Source: Rehab Seating & Database Coordinator Physical Medicine and Rehabilitation Centre 8th Floor Rehab Centre Bed Day Utilization by Fiscal Year 1, Bed Days 8, 6, 4, Hospitalist Physician Source: Divisional Data AMPS Gen Neuro Consult MSK SCI Stroke TBI Sub- Acute Avg Wait (Days) Avg Wait (Days) Avg Wait (Days) Avg Wait (Days) Avg Wait (Days) ALC 2, Bed Days Unused Bed Days Used 6,867 7,985 5,482 6,358 7,263 Available 7,58 8,523 5,644 6,44 7, DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION

177 Ambulatory Care Division members provided specialized consultation for 3,695 outpatients in 212/13 including 16 registrations to the Cobequid Community Health Centre not included in the figure below. This includes General Physical Medicine and Rehabilitation patients and specialized clinics for ALS, Spasticity Management, Amputee, Traumatic Brain Injury, Stroke, Neuromuscular, Multiple Sclerosis, Spinal Cord Injury, Musculoskeletal, 515 NCV/EMG registrations as well as the 28 new and 48 return TeleHealth visits to patients outside the Capital Health District. There were an additional 87 chart checks performed in 212/13 not reported in the following figures. Figure 15 Physical Medicine and Rehabilitation New and Return Ambulatory Care Registrations 3,5 Registrations 3, 2,5 2, 1,5 1, Code Missing New Return 1,895 1,98 2,42 2,614 2,283 Total 2,449 2,755 3,188 3,277 2,998 % New 22.4% 27.9% 23.7% 2.% 23.4% Figure 17 Physical Medicine & Rehabilitation Ambulatory Care Registrations 3,5 Registrations 3, 2,5 2, 1,5 1, DIVISION OF PHYSICAL MEDICINE & REHABILITATION Figure 16 Physical Medicine and Rehabilitation EMG New and Return Ambulatory Care Registrations 6 Registrations Orthotics 1 Sexual Health 14 4 ALS Acquired Brain Injury Muscular Sclerosis Traumatic Brain Injury Stroke Spinal Cord Injury Neuromuscular Musculoskeletal Rehabilitation Spasticity Amputee Total 2,457 2,755 3,191 3,288 2, Code Missing New Return Total % New 97.5% 98.7% 98.2% 98.2% 98.4% DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION 171

178 DIVISION OF PHYSICAL MEDICINE & REHABILITATION Triage Guidelines & Wait Times Table 2 Guidelines for Triage of New Referrals to Physical Medicine & Rehabilitation Outpatient Clinics *Consults are triaged (urgent, semi-urgent, non-urgent) into the following sub-specialty categories: Sexual Health Botox Amputee Traumatic Brain Injury Stroke Neuromuscular Multiple Sclerosis Spinal Cord Injury Musculoskeletal Urgent Category A Examples include: Sudden and marked decline in function Post-acute stroke rehabilitation (inclusive of all sub-specialty areas) Medical instability related to a rehabilitation diagnosis (e.g. autonomic dysreflexia in a spinal cord injury patient) Semi-Urgent Category B Examples include: Decline in function over weeks to months Acute musculo-skeletal impairments Change in spasticity Amputation Non-Urgent Category C Examples include: Assessment and management of the above sub-specialty areas Standard Wait Time Within 1 week (7 Days) Within 4 weeks (28 Days) Within 12 weeks (84 Days) Figure 18 Figure 19 Figure 2 Physical Medicine and Rehabilitation New Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 14% 42% 22% 36% 14% 27% 17% 17% Source: PHS Data Physical Medicine and Rehabilitation New Semi-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 15% 12% 1% 9% 14% 17% 12% 6% Source: PHS Data Physical Medicine and Rehabilitation New Non-Urgent Consults Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 49% 23% 26% 13% 17% 5% 26% 2% Source: PHS Data 172 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION

179 No Show The overall no show rate for 212/13 was.7%. Patients are called to remind them of their appointments. This does help to reduce the number of patients who do not show up for their appointments. It also allows for cancelled appointments to be filled with other patients on the waiting list. Distribution of Patients by Age Figure 21 Physical Medicine and Rehabilitation Clinic Registrations Percent Distribution by Age and Gender QEII Health Sciences Centre, Age Group 9+.2%.5% % 18.6% 19.5% 8.9% 11.5% 7.9% 3.3% 2.7% 2.6% 1.5% 8.1% 1.9% 9.% 16.7% 24.4% 26.3% 5% 4% 3% 2% 1% % 1% 2% 3% 4% 5% Female Male Distribution of Patients by District Education We continue to provide undergraduate and postgraduate level teaching at Dalhousie medical school and in the health sciences programs as well. Our members are very active in Continuing Medical Education and continue to participate in local, national and international events. Undergraduate Medical Education The division offers elective and selective rotations throughout the curriculum. 23 undergraduate medical students and clinical clerks rotated through the division during 212/13. Division members provided 8 hours as rotating elective tutors, 28 hours Med 2 Case Based Learning tutorials, 12 hours of Clinical Skills Teaching, 15.5 hours as Med 2 OSCE examiners and 8.75 hours as Med 3 OSCE examiners. Additionally, division members provided 2 hours of lecturing in the IMU link program. Postgraduate Medical Education DIVISION OF PHYSICAL MEDICINE & REHABILITATION Figure 22 Physical Medicine and Rehabilitation Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, NB, NF, PEI: 14 SWH: 9 The Royal College of Physicians and Surgeons accredited PM&R resident training program attracts high quality applicants to the program. 3 residents from Psychiatry and Neurology rotated through the division in 213/14. We had two of our trainees successfully complete their royal college exams this year and welcomed a new PGY1 trainee. SSH: 169 PCHA: 131 GASHA: 61 CHA: 59 CDHA: 1,991 CEHHA: 23 CBDHA: 83 AVDHA: 197 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION 173

180 DIVISION OF PHYSICAL MEDICINE & REHABILITATION Research We continue with a productive research program with nine published papers, four book chapters and 36 abstracts and presentations. Twenty-two students and residents were mentored through our division. Our division brought in $187, dollars in research funding. This was a combination of clinical trials, investigator initiated trails, CIHR ($67,34.) and collaborative research with external research groups. Dr. R.L. Kirby 5% of his time is protected for research (.45 of a total of.9 FTE). During the past year, he continued his research into the safety and performance of wheelchairs. This has included applications to funding agencies, supervision of research students, publications and presentations. Through committee work and review activities, he has also facilitated the research of others. Dr. E. Hanada 4% of his time is allocated for research. During the past year, he continued his research into developing technology to facilitate rehabilitation care. Activities that he has undertaken for his research program has included applications to funding agencies, supervision of numerous research students, publications, and presentations, both at the local and national levels. Through committee work, grant and journal submission review activities, editorial work, and mentorship, he has also contributed to the others research progress. Administration Division Members Act as Directors/Chairs for: Division Head / Service Chief Clinical Locomotor Function Laboratory, Director Research, Director Residency Training, Director Canadian Academy of Sport Medicine, Sport Safety Committee, Chair Canadian Paraplegic Association Board of Directors, Vice-Chair GGM Unit, Musculoskeletal Component, Chair Internal Review Committee Psychiatry Residency Training Program, Chair Musculoskeletal Program, Chair Neurorehabilitation Program, Co-Chair Rehabilitation Research Committee, Chair Stroke/ABI Program, Medical Chair 174 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF PHYSICAL MEDICINE & REHABILITATION

181 Division of Respirology DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF RESPIROLOGY 175

182 DIVISION OF RESPIROLOGY Physician Resources There are 4 full time physicians, 4 part time physicians and 1 part time community-based physician who provide specialist service in the Division of Respirology. The total complement is 6.6 FTE s. Clinical Services Specialized respiratory care is provided for patients in the Capital District Health Authority and tertiary care is provided for the province. The clinical responsibilities of the division s physician members include the following ambulatory and inpatient services: Respirology Clinic Rapid Referral Clinic Inpatient consultations & Emergency Emergency Coverage Physicians provide 24 hour, 7-day emergency and on-call coverage for patients in the province. Division members provided 4 weeks of ED on-call service. Inpatient Services There are no designated respirology beds. Respirologists, however, play a significant role as attending physicians on the Department of Medicine s Medical Teaching Unit, IMCU and on the respirology inpatient consult service. Division members provided 4 weeks of service as attending physicians to the MTU, 32 weeks of attending physician coverage to the IMCU, and 24 weeks of PAH call. There are 3 beds available for sleep studies at the Sleep Disorders Clinic, Abby J. Lane Building. The Sleep Program is directed by respirologist Dr. Debra Morrison. Inpatient Consultations Figure 1 Respirology Inpatient Consults 2,5 # Consults 2, 1,5 1, New Continuing Care 1,2 1,175 1,74 1,27 1,13 Total 1,96 1,839 1,757 1,889 1,755 Source: Divisional Data Inpatient consultation service is provided by respirologists to other services at the Halifax Infirmary, VG and Rehab sites as well as occasional consultations to the IWK Health Centre. 742 patients were seen in consultation in 212/13, this generated an additional 1,13 Continuing Care visits during hospitalization. Pulmonary Rehabilitation Program Adult Cystic Fibrosis Clinic Sleep Disorders Clinic and Laboratory Pulmonary Function Laboratory Bronchoscopy PAH Program - shared 176 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF RESPIROLOGY

183 Ambulatory Care Members of the Division of Respirology provided care for 3,775 outpatients in 212/13 including General Respirology Clinic (figure 2) and specialized clinics for Cystic Fibrosis (figure 3). These registrations do not include the outpatient visits conducted in the sleep program and the shared PAH Clinic. There were an additional 277 chart checks performed in 212/13 not reported in the following figures. Figure 2 Respirology New and Return Ambulatory Care Registrations 5, 4, Figure 3 Respirology Cystic Fibrosis New and Return Ambulatory Care Registrations 4 Registrations New Return Total % New 3.9%.8% 2.7% 19.8% 31.9% Sleep Studies Figure 5 Location: Sleep Lab 4th Floor AJL Ambulatory Care Registrations 5 Registrations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total , , , , ,419 DIVISION OF RESPIROLOGY Registrations 3, 2, Figure 4 The number of visits to the sleep lab was 2,419 for 212/13. 1, New 1,119 1,27 1,27 1,116 1,71 Return 2,99 2,412 2,564 2,567 2,378 Total 4,28 3,511 3,771 3,683 3,449 % New 27.8% 29.3% 32.% 3.3% 31.1% Pulmonary Rehab Clinic Visits Visits Source: Divisional Data The graph above includes Pulmonary Rehab Clinic patient visits. These patients have been referred to the clinic by Division of Respirology physicians. Patients visit the clinic twice a week for 12 weeks. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF RESPIROLOGY 177

184 DIVISION OF RESPIROLOGY Technical Procedures Figure 6 Pulmonary Function Diagnostic and Therapeutic Registrations 1, Bronchoscopies There were 87 bronchoscopy procedures in 212/13 performed by division members. Pulmonary Arterial Hypertension The Pulmonary Arterial Hypertension (PAH) Program is a multidisciplinary program shared by Rheumatology, Cardiology and Respirology specialists. The clinic is run at the NSRC. Respirology physicians had 86 registrations in 212/13. Registrations Figure Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total , , , , ,59 Pulmonary Arterial Hypertension (PAH) Program Ambulatory Care Registrations 35 Registrations Respirologists are responsible for interpreting and reporting test results for the Pulmonary Function lab. 1 5 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF RESPIROLOGY

185 Triage Guidelines & Wait Times Table 1 Guidelines for Triage of New Referrals to Respirology Outpatient Clinics Respirology Urgent Suspicious for lung cancer, PCP, TB Initiation of home oxygen Unstable asthma/copd Recurrent ER visits for respiratory symptoms Hemoptysis Standard Wait Time Within 5 days Figure 8 Respirology New Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days DIVISION OF RESPIROLOGY Respirology Semi- Urgent Asthma/COPD - severe Interstitial lung disease not yet diagnosed Pulmonary rehabilitation Pulmonary hypertension Progressive neuromuscular disease Within 42 days 1 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 1% 9% 87% 1% 87% 68% 1% 1% Source: PHS Data Respirology Elective Sleep disordered breathing Asthma/COPD stable Long standing cough Respirology Sleep Urgent Nocturnal hypoventilation disorders with impending respiratory failure Severe daytime sleepiness leading to an urgent public safety issue Respirology Sleep Semi-Urgent Severe sleep apnea in the setting of significant medical illness i.e. congestive heart failure, pulmonary hypertension, poorly controlled hypertension, recent stroke, etc. Sleep disorders with severe daytime symptoms Respirology Sleep Elective All other sleep apnea Periodic limb movements and restless leg syndrome if does not meet the criteria of categories 1 or 2 Narcolepsy if does not meet the criteria of categories 1 or 2. Other adult sleep disorders REM behaviour disorder, unusual parasomnias, etc. Insomnia referrals of patients with known psychiatric diagnoses are discouraged, with request for patients to be assessed by their psychiatrist. Within 7 days Within 14 days Within 84 days Within 365 days Figure 9 Respirology New Semi-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 87% 87% 88% 86% 69% 72% 71% 8% Source: PHS Data DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF RESPIROLOGY 179

186 DIVISION OF RESPIROLOGY Figure 1 Respirology New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 24% 23% 19% 27% 55% 51% 19% 4% Figure 12 Respirology Sleep Lab New Semi-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 36% 21% 5% 79% 67% 53% 39% 47% Medical Day Unit There were 1 patient visits referred by division physicians in the Medical Day Unit in 212/13. Clinic No Shows There were 17 no shows recorded in PHS for 212/12. This represents 3.3% of total bookings. Source: PHS Data Figure 11 Source: PHS Data Figure 13 Discharges Respirology Sleep Lab New Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard 14% 75% 1% 83% 1% 25% 1% 5% Respirology Sleep Lab New Non-Urgent Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, Days Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait ,232 1,27 % Within Standard 17% 24% 5% 12% 75% 8% 71% 6% There were 945 patients discharged back to their primary care physician in 212/13. Source: PHS Data Source: PHS Data 18 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF RESPIROLOGY

187 Distribution of Patients by Age Figure 14 Respirology Clinic Registrations Percent Distribution by Age and Gender QEII Health Sciences Centre, Age Group % 21.1% 21.6% 12.8% 6.5% 5.1% 4.6%.5%.6% 1.% 3.6% 3.3% 1.1% 8.% 11.4% 21.9% 21.2% 28.8% Distribution of Patients by District Figure 15 Respirology Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, Other: 3 NB, NF, PEI: 86 SWH: 72 SSH: 95 PCHA: 45 GASHA: 19 CHA: 49 CEHHA: 256 CBDHA: 3 CDHA: 2,689 Education Undergraduate Medical Education Members of the Division make a significant contribution to Dalhousie s undergraduate program, providing lectures, tutorials, bedside teaching and laboratory sessions. Dr. Nancy Morrison serves as Chair of the Department of Medicine s Undergraduate Education Committee. 14 undergraduate medical students and clinical clerks rotated through the Division in 212/13. Division members provided 2 hours as tutors for Med 2 case based learning. DIVISION OF RESPIROLOGY 4% 3% 2% 1% % 1% 2% 3% 4% Female Male AVDHA: 15 Respirologists provided 24 hours of Med 2 Clinical Skills training. Division physicians provided 7.75 hours as examiners for Med 2 OSCEs and 6 hours as examiners for Med 3 OSCEs. Respirologists provided 3 hours of lectures to IMU link students and 8 hours of lectures for Med 1 rotating electives. Postgraduate Medical Education 21 Internal Medicine Core Residents and 13 Non Medicine Residents from Neurology, Anaesthesia and Radiation Oncology rotated through the Respirology service during the 212/13 academic year. Respirologists acted as examiners for 1 hours of resident OSCEs in 212/13. 3 Academic half-day sessions were presented to core internal medicine residents by Respirology in 212/13. DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF RESPIROLOGY 181

188 DIVISION OF RESPIROLOGY Research The Division generated $333,315 in research funds and industry contracts during 212/13. Administration Division Head/Service Chief, including all responsibilities of the position. Division members act as Directors/Chairs for: Chair, Respirology Residency Program Content Subcommittee Chair, Respirology Fellowship Admission and Evaluation Committee Chair, Morbidity & Mortality Rounds Chair, Internal Medicine IMCU Committee Chair/President, Atlantic Thoracic Society Advocacy Committee Chair, Canadian Thoracic Society COPD Guidelines Dissemination and Implementation Committee Chair, Canadian Thoracic Society COPD and Pulmonary Rehabilitation Clinical Assembly Chair, Medical Advisory Board, Nova Scotia Lung Association Co-Chair, Respiratory Clinical Services Committee Director, Sleep Clinic & Laboratory Director, Adult Respirology Residency Training Program Director, Research Director, Undergraduate Medical Education Executive and Chair Scholarship and Bursary Committee, Women s Division, Dalhousie Alumni Governor, Atlantic Region, American College of Chest Physicians Head, Metabolism II Curriculum Renewal Committee Medical Director, Internal Medicine IMCU Medical Director, Pulmonary Function Laboratory Medical Director, Pulmonary Rehabilitation Program Medical Director, Adult Cystic Fibrosis Clinic Medical Director, Atlantic Sleep Institute Vice-Chair, Canadian Thoracic Society, COPD and Pulmonary Rehab Committee Vice-Chair, Canadian Thoracic Society, Canadian Respiratory Guidelines Committee 182 DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF RESPIROLOGY

189 Division of Rheumatology DEPARTMENT OF MEDICINE COMPENDIUM OF DIVISIONAL ACTIVITY DIVISION OF RHEUMATOLOGY 183