Professional Documents
Culture Documents
The Procurement of
Anaesthesia Volatile Agents:
an Evidence-Based Review
Leadership Report
Community RT
Research
Management Corner
Student Corner
CIHI Update
Ask aRTee
www.rtso.ca
Presidents Message
Kyle Davies RRT BSc
Support for your COPD patients
RxTelehomecare.ca
1.855.991.8191
Telehomecare is a program of the Ontario Telemedicine Network, a non-profit organization supported by
the Ontario Ministry of Health and Long-Term Care and Canada Health Infoway.
Kyle
Page 2
Editorial
Leadership
Namaste,
Kyle Davies
References:
1. www.dayofhappiness.net
2.
3.
4.
http://idea-international.org
RRT BSc
Correction Notice
In the winter edition of RTSO Airwaves, the student corner article entitled Discovering
Respiratory Therapy as a Student at La Cit the name of our contributor was misspelled.
The correct spelling is Stphane Lauzon and not Stephan Lauzon as published.
We sincerely apologize for any inconvenience this may have caused.
Page 4
Ginny Myles
Sara Han
Page 6
http:www.rtso.ca/rtso-membership-application/.
Better yet, encourage your colleagues to also
join, contribute to, and continue this work.
Please email Ginny Myles (mylesg@tvh.on.ca)
or Sara Han (shan@on.lung.ca) to learn more.
Research
Page 8
Imaging Platform
Dr. Grace Parraga (James Robarts Research
Institute, University of Western Ontario, London ON)
Goals: To expand use of novel CT and MRI for
COPD patient phenotypes to 4 or 5 geographical
nodes in Canada; and to enable novel pulmonary
imaging platforms across CRRN nodes and
Physiology Platform
Dr. Denis ODonnell (Queens University,
Kingston ON)
Goals: To identify the most sensitive test(s) of
peripheral airway dysfunction for earlier diagnosis
and more accurate prognosis of smokers and nonsmokers who are susceptible to airway injury; and
to support the other CRRN platforms by providing
a comprehensive physiological characterization
and phenotyping of small airway dysfunction.
Biomarker Platform
Dr. Don Sin (University of British Columbia,
Vancouver BC )
Goals: To determine novel molecular targets of
airway disease as a foundation for biomarker
discovery; and to use emerging genomics and
proteomics tools to better phenotype cohorts
and to develop novel biomarkers to predict
development and progression of chronic airway
diseases.
Cohort Platform
Dr. Jean Bourbeau (McGill University, Montreal QC)
Dr. Wan Tan (University of British Columbia)
Goals: To identify potentially modifiable risk
factors for COPD besides cigarette smoking.
CanCOLD is a prospective longitudinal
cohort study that includes > 1300 subjects
followed prospectively over years and will
serve as a resource for multiple network
studies and platforms.
Page 10
Project 2:
Project 1:
Identification of Undiagnosed Airflow
Obstruction in the Canadian Population: Patients
found to have undiagnosed COPD or asthma in
our Health Services Research Platform would
be further studied using advanced airway
physiology, airway imaging, and biomarkers of
airway inflammation to assess pathophysiology
and functional impairment. As well, we will
determine the health economic impact of our
screening and early treatment strategy from a
patient-based and societal perspective by linking
to the Health Economics Platform.
Project 3:
Using the Canadian Cohort of Obstructive
Lung Disease (CanCOLD) we will determine
whether the presence of small airway disease
(or bronchiolitis) is predictive of rapid decline in
lung function.
Potentially pre-clinical small airway disease in
CanCOLDcohort subjects will be diagnosed
through advanced airway imaging techniques,
advanced physiologic testing of small airway
disease, and through our biomarker discovery
platform.
Project 4:
This study intends to use
pharmacoepidemiological data to determine
if poor control of airway disease in asthmatic
preschoolers leads to increased severity and
progression of chronic airway disease in later life.
This project will link to our environmental health
and population health platforms to determine if
exposure to ambient air pollution is associated
with poor asthma control in young children.
The economic impact of asthma in preschoolers
and adolescents and healthcare delivery to this
vulnerable subgroup will be studied by the
CRRNs health economics and health services
research platforms.
CRRN will serve as a structural foundation
for network-based investigators to leverage
PATIENT ENGAGEMENT
The CRRN will partner with the Canadian Lung
Association to ensure patient engagement in
our network.
An asthma app (called breathe) has been
developed by three co-investigators in the
CRRN Environmental Health Platform. This
initiative is being coordinated by the Ontario
Lung Association. The breathe app helps asthma
patients to keep track of their symptom controls
with electronic real time symptom diary and an
action plan. Through the app, we also push realtime air quality data to the patients to help them
modify their outdoor activities with the knowledge
of the potential adverse environmental exposures.
Patient engagement is front and center of this study.
http://www.on.lung.ca/breathe-App
KNOWLEDGE TRANSLATION
CRRN has adopted the CIHR Knowledge-toAction Cycle as the framework to guide the
development, translation and synthesis of evidence
that CRRN will produce. A key aim is to adopt an
integrated knowledge translation approach that
engages potential knowledge users as partners
in the research process. As knowledge gaps are
identified, new projects will be developed to
address these gaps by liaising with key knowledge
users (patients, families, healthcare providers)
via the Canadian Lung Association, and with our
industry and governmental partners.
Industry Contributions:
Gold Partners
GSK
Astra Zeneca
Boehringer Ingelheim
Silver Partners
Novartis
Bronze Partners
Merck
Spring Inspirations
London, ON
Tuesday, June 9, 2015
8:00 a.m. - 4:00 p.m.
Best Western Lamplighter Inn
591 Wellington Road South, London
RTWB - An Update
Respiratory Therapists
Without Borders
(RTWB)
Nepal
It is with great joy that when the RTSO asked for an update from the Respiratory Therapists Without Borders
(RTWB) I write to you. The RTSO Board from 2010 played a vital role in nurturing the idea of RTWB long before it
became a registered charity in 2014. As testament today, RTSOs fingerprints continue to be all over RTWB with 3
of our directors and 2/3 advisors being Ontario Respiratory Therapists. Its a joy to continue receiving your support
with a complementary booth at the 2015 RTSO Education Forum in November. We look forward to seeing you
then if not earlier. Below is a sneak peak at the 1st quarter update.
All the best,
Eric Cheng
3. Communications
Dear RTWB Team and supporters,
It is with your support that Respiratory Therapists
Without Borders / Inhalothrapeutes Sans Frontires
(RTWB/ISF) continues to grow. Thank you! We
continue to run as a completely volunteer run
charity to improve respiratory health through
educational advancement of local healthcare
providers worldwide.
Page 14
RTWB - An Update
Danny Ties
Left: National NSCCM Conference
2014
TM
Sil.Flex Stoma
and TC Pads
TM
Innovative cushions
absorb pressure at
stoma sites
Peace,
Eric Cheng
Co-Founder & Culture Creator
Respiratory Therapists Without Borders
Registered Canadian Charity (3 833885437RR0001)
eric@rtwb.ca; www.rtwb.ca
1.778.239.9335
All photos courtesy of RTWB
THE PROCUREMENT OF
ANAESTHESIA VOLATILE
AGENTS: AN EVIDENCEBASED REVIEW
Introduction
Patient safety is a priority in providing patient
care in any healthcare setting, particularly in
the operating room. There are many issues to
take into consideration related to each patient
care intervention in order to achieve the best
processes to affect the best outcomes for
patients with minimal risk for adverse outcomes
for providers.
Submitted by
Rob Bryan, A-EMCA, RRT, AA
Page 18
Procurement strategy
for anaesthesia volatile
agents in Ontario
Volatile agents are pharmaceutical drugs available
in a liquid form that are vapourized through the
use of specialized equipment during operating
room procedures in order to provide varying
levels of sedation to patients undergoing surgical
procedures. Modern anaesthesia volatile agents
commonly used in most operating rooms are
known as halogenated ethers such as Isoflurane,
Desflurane and Sevoflurane. These agents are
generally considered to be safe and have unique
clinical benefits and characteristics used in a
variety of different patient care scenarios. Due to
the chemical nature of volatile anaesthetic agents
and the way they are dispensed and administered,
there are many considerations and hazards to both
the patient and the staff that must be considered
when establishing a volatile agent delivery system
and procurement strategy.
The procurement and purchase of anaesthesia
volatile agents in Canada requires in-depth
knowledge and understanding of the available
volatile agents, formulations, clinical use,
governmental regulations and industry
standards around safe handling, storage, applied
technologies and environmental effects to be
taken into consideration when selecting a volatile
agent and delivery system for clinical use.
Traditionally the responsibility of procuring and
purchasing volatile agents relied heavily on
the expertise and collaboration of anaesthesia
and pharmacy services to guide the purchasing
department in securing a contract best suited to
the hospitals anaesthetic volatile agent needs.
Methodology
In order to assemble a thorough body of relevant
clinical evidence and standards that can inform
the procurement and use of anaesthesia volatile
agents, two main approaches were used: a
medical literature search with the assistance of
a medical librarian using keywords and phrases
such as: waste anesthetic gases (WAGs), volatile
anaesthetic agent formulations, and safe handling
of anaesthesia agents in the operating room;
and references to several regulatory bodies
and associations from across North America
and Europe regarding current standards and
occupational health and safety regulation
including the Canadian Centre for Occupational
Health and Safety the United States (U.S.)
Centre for Disease Control National Institute
for Occupational Safety and Health, the U.S.
Department of Labor Occupational Safety and
Health Administration, and the International Social
Security Association Section on the Prevention
of Occupational Risks in Health Care. Product
monographs and Food and Drug Administrations
information from Canada and the U.S. - were
referenced as well as web based resources from the
Canadian Anaesthesia Society, American Society of
Anesthesia and The Association of Anaesthetists of
Great Britain and Ireland.
Page 20
Page 22
Volatile Agents:
Formulations and
Packaging
There are three anaesthesia agent pharmaceutical
providers in todays Canadian health care market.
AbbVie (formally Abbot), Baxter Corporation and
Piramal Healthcare. All produce and sell modern
halogenated volatile agents - particularly isoflurane,
sevoflurane and desflurane.
Isoflurane is a halogenated methyl ether12 and is
produced and sold by Abbvie, Baxter and Piramal.
It is less expensive than sevoflurane and desflurane
but its clinical use and appeal has waned due
to its association with cardiac steal in patients
Originally published
[Edmond I. Eger, II, MD,
Characteristics of Anesthetic
Agents Used for Induction
and Maintenance of General
Anesthesia, Am J Health
Syst Pharm. 2004;61(20) ]
[2004], American Society of
Health-System Pharmacists,
Inc. All rights reserved.
Reprinted with permission
(R1501).
Page 26
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14.
15.
16.
17.
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Abstract/2007/06000/Sevoflurane__Are_There_Differences_in_
Products_.22.aspx
Kharasch ED - Sevoflurane: the challenges of safe formulation. APSF
Newsletter, 2007;48:55. http://www.apsf.org/newsletters/html/2007/
fall/03_sevoflurane.htm
ONeill B, Hafiz MA, DeBeer DAH - Corrosion of Penlon sevoflurane
vaporisers. Anaesthesia, 2007;62:421. http://onlinelibrary.wiley.com/
doi/10.1111/j.1365-2044.2007.05048.x/full
Kharasch ED, Subbarao GN, Stephens DA et al. - Influence of
sevoflurane formulation water content on degradation to hydrogen
fluoride in vaporizers. Anesthesiology, 2007;107:A1591. http://www.
asaabstracts.com/strands/asaabstracts/abstract.htm?year=2007&index=
15&absnum=1758
Stephens DA, Kharasch ED, Cromack KR et al. - Sevoflurane vaporizers
contain Lewis acid metal oxides that can potentially degrade
sevoflurane. Anesthesiology, 2007;107:A1597. http://www.asaabstracts.
com/strands/asaabstracts/abstract.htm?year=2007&index=15&absn
um=972
Cromack KR, Kharasch ED, Stephens DA et al. - Influence of formulation
water content on sevoflurane degradation in vitro by Lewis acids.
Anesthesiology, 2007;107:A1593. http://www.asaabstracts.com/strands/
asaabstracts/abstract.htm?year=2007&index=15&absnum=770
Grupa A, Ely J - Faulty sevoflurane vaporizer. Anesthesia, 2007; 62:412.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2007.05049.x/full
Baker MT, Sevoflurane-Lewis Acid Stability, Anesth Analg 2009; Vol
108;1725-1726
Barash Paul G., Cullen F. Bruce, Stoelting Robert K., Cahalan Michael,
Stock Christine Generic Sevoflurane Formulations. Clinical Anesthesia,
6th edition, (978-0-7817-8763-5), page 423, chapter 17
Piramal Critical Care Inc., Urgent Drug Recall Notification Letter , dated
April 3, 2014 , issued by Eric L. Wesoloski Director of Quality
McNeirney, John C., Chief Technical Officer Mindrad, Dr Terrel, Ross
Minrad PhD, Minrad. Complex Chemistry Causes Controversy Minrad
Provides Packaging Perspective, Anesthesia Patient Safety FoundationAPSF newsletter Winter 2007-2008, pages 85-86
Jean-Frangois Hardy, letter to the editor Vaporizer Overfilling, Canadian
Journal of Anaesthesia , January 1993, Volume 40, Issue 1, pp 1-3
FDA Piramal Critical Care Inc, Sevoflurane recall enforcement
report week of May 7, 2014, http://www.accessdata.fda.gov/scripts/
enforcement/enforce_rpt-Product-Tabs.cfm?action=select&recall_
number=D-1262-2014&w=05072014&lang=eng
Fluoride Action Network, Review of Form 483 from FDA News:
Sevoflurane: Use of Potable Water Gets Drugmaker a 483, http://
fluoridealert.org/news/sevoflurane-use-of-potable-water-getsdrugmaker-a-483/
Student Corner
My Transition
from SRT to RRT
The end of clinical quickly approaches by finishing
off major case presentations and preparations
for the national exam. I attended the Michener
Institute for Applied Health Sciences for Respiratory
Therapy in Toronto. Although the end was near for
formal education, the real learning occurs once
you enter the field on your own as a new graduate.
Towards completion, I experienced a roller coaster
of emotions: a feeling of excitement of completing
my education; a gratifying feeling to be financially
compensated; and an eagerness to apply my skills
to improve a persons quality of life; I also had
feelings of uncertainty in regards to job prospects,
anxiety of conquering the national board exam, the
stress of maintaining patient care and safety on my
own and fitting into the workplace.
The first thought that comes to a new graduates
mind is, will I be able to secure a job?. My
classmates and I were told from the start of clinical
that job prospects were gloomy and we would
likely attain casual positions, if there are any at all,
in Toronto. I strongly considered moving out west
but decided to try and exhaust options here first,
as Toronto is home. I was fortunate enough to
experience a number of interviews, and in the end
accepted two casual positions before graduation. I
was overwhelmed at first as to how to manage both
positions, but scheduling was easier than expected
since one of my jobs is in acute care (with a set
schedule as per availability) and the other job is in
Page 32
Student Corner
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epoc isa trademark of Epocal Inc. under license. PN: 1000376-01 12/11
Management Corner
Dont let your ego get in the way of your desire to
learn. Successful people keep their minds open
to new things because they know that no matter
how high their level of mastery, there is always
more to discover. If youve become an expert
in one specific aspect of the RT role, seek out
other fields where you can transfer and apply
your expertise. When facing challenges, even
ones youve faced many times before, adopt a
learners approach; ask questions or find new
ways to solve the problem.
Lucy Bonanno
RRT, MA, MBA, CAE, CHE
36
More reasons to be a
member of the RTSO
1. Leadership - Province wide peer support
and networking opportunities
2. Community RT advocacy to ensure better
care for the patient in the community
647-729-7217 / 1-855-297-3089
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Got a question for aRTee?
Contact the RTSO at
office@rtso.ca and your
question may be featured
in an upcoming edition of
RTSO Airwaves.
Ask aRTee
Dear aRTee,
My hospital will be going through Accreditation
in June and I keep hearing talk of ROPs. I dont
know what that means and Im too embarrassed to
ask. Can you help?
Thanks,
Clueless Cal
Dear Cal,
Accreditation is a continual process of assessing
your organization against standards to identify
what you do well, where you can make
improvements, and how make those improvements
happen.
According to Accreditation Canada1, accredited
employers have demonstrated commitment to:
Improving quality and safety
Reducing risk
2. http://www.accreditation.ca/sites/default/
files/rop-handbook-2015-en.pdf
3. http://www.accreditation.ca/sites/default/
files/rop-handbook-2016-en.pdf
Increasing efficiency and decreasing costs
Implementing best practices
An ROP is a Required Organizational Practice
there are many ROPs that are evidence-based
practices, proven to reduce risk and improve
quality and safety when implemented1. ROPs are
developed using a similar process to that of the
standards - utilizing consultation, research, and
evaluation to build.1
In Canada, ROPs are an important part of the
accreditation program, addressing vital safety
issues within six safety goal areas, and there is
something called primer standards, with these
divided into nine sections1:
Leadership
Client Safety
Integrated Quality Improvement
Safe and Healthy Worklife
Information Management
Physical Environment and Equipment
Medication Management
Page 36
References:
1. Accreditation Canada http://www.
accreditation.ca/accreditation-menu
www.rtso.ca
www.rtso.ca
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