Last month, the Commission on the Reform of Ontario’s Public Services (the ‘Drummond Report’) was released and presented to the Ontario Government.  This report provides a sober review of the Ontario economy and includes 362 recommendations to address a number of areas in an effort to improve the efficiency and effectiveness of Ontario’s public services.

It’s important to note that over 100 of these recommendations address health care.  The report acknowledges that many of the health care recommendations are not new, or radical, and in many instances recognizes the system is moving towards the kind of reformed care that’s needed.

Last September, CAHO met with the Drummond Commission to provide our perspective on the role of academic research hospitals and how they can help improve health care.  CAHO answered questions on a number of different subjects including the leadership role research hospitals provide in the health care system, improving integration across the system’s various providers, and the challenges regarding health research funding in Ontario, to name a few.

There are many recommendations of interest to the CAHO community in the Drummond Report.

In particular, the report recommends awarding research funding more strategically and managing it more efficiently.  This recommendation is consistent with CAHO’s long-term advocacy in favour of a Health Research and Innovation Council.  An overarching health research strategy would ensure the innovation cycle from discovery to practice is complete, and would deliver better health outcomes and economic growth by attracting the best researchers to Ontario.

It also calls for the identification of a regional health authority as the key point for interaction and providing services across a geographic area.  While the Commission recommends LHINs, they also recognize this role could be played by academic hospitals.

Lastly, the report calls for the expansion of the mandate of Health Quality Ontario to become a regulatory body to enforce evidence-based directives to guide treatment decision and coverage.  We welcome the focus by the Commission on the importance of evidence-based policy.

CAHO Catalyst recently sat down with Sharon and asked her to reflect on the MOVE ON application and her research at St. Michael’s.

Can you briefly describe to our readers what the MOVE ON project is and what inspired the research and development of this application?

We’re interested in implementing and evaluating an evidence-based strategy to promote early mobilization and prevent functional decline in older patients admitted to acute care facilities in Ontario. We decided to tackle this issue because the rates of mobilization of patients admitted to acute care hospitals are very low. Studies show that hospitalized older adults who were ambulatory during the two weeks prior to admission spent a median of 43 minutes per day standing or ambulating.

And, there are downsides to immobility – it’s hazardous to the well-being of the patient and can impact their ability to participate in normal activities of daily living like toileting themselves. It can also lead to longer length of hospital stay amongst other outcomes.  Studies have shown that one-third of older adults develop a new disability in an activity of daily living during hospitalization and half of these are unable to recover function.

Randomized trials show that early mobilization (assessing people for mobility status within 24 hours of admission and encouraging appropriate activity immediately) can be effective. For example we know they can:

• decrease acute care length of stay (adjusted absolute difference of 1.1 days [95% confidence interval [CI] 0.0 to 2.2 days]);
• shorten duration of delirium (median of 2 days [inter-quartile range 0.0 to 6.0] versus 4 days [inter-quartile range 2.0 to 8.0]);
• improve return to independent functional status (odds ratio [OR} 2.7 [95% CI 1.2 to 6.1]);
• decrease risk of depression (OR 0.14 [95% CI 0.03 to 0.61]);
• increase rates of discharge to home (26.2% versus 2.4% at 7 days); and,
• decrease hospital costs by $300/patient/day

Can you share with us what the objective of the MOVE ON project is and what your team and CAHO is trying to achieve?

We will use an integrated KT approach to tackle this challenge – this refers to a collaborative process whereby researchers and research users (clinicians) work together to design the implementation process.  And the implementation is modified according to the context in which it is being used – so it’s not just a simple plug and play.  We want to make sure the intervention is appropriate for the setting and circumstances.

Through this project, we will collectively implement an inter-professional approach that focuses on early and consistent mobilization of older patients throughout the hospital stay.  This strategy shifts mobilization from being a designated task assigned to a single professional group to a shared team responsibility, with each team member having complementary roles.

Our key messages for the sessions will focus on actionable recommendations: at least three times a day, progressive, scaled mobilization; and mobility assessment and care pathway to be implemented within 24 hours of the decision to admit. 

Ideally we’d like to make sure that all patients are mobilized when in hospital to preserve their function – but for this project we’re targeting older adults in particular.

Can you share with us a preview of some of the early learnings from the CAHO MOVE ON ARTIC project?

Data from observations on inpatient units conducted in 2010-2011 in academic hospitals in Toronto found that less than 30% of older patients were mobilized regularly in hospital – this is a substantive issue!

Our work to date has also highlighted how important it is to ensure that the implementation intervention is contextualized to the institution to ensure that it is appropriate for that environment. 

Another key learning is how important it is to have a collaborative, multidisciplinary team to work on projects like these.  We have a wonderful team working on this project and I am fortunate to work with the fantastic Dr. Barbara Liu who is based at Sunnybrook Hospital. 

Can you describe to our readers research you and your team are working on in addition to the MOVE ON application at St. Michael’s?

We are working on a number of projects focused on advancing the practice and science of knowledge translation.  These initiatives target patients, managers and health care providers.  Some examples include implementation and evaluation of a delirium prevention strategy in acute care, and implementation and evaluation of self management tools for patients with chronic diseases (such as urinary incontinence and osteoporosis).  We are working with a number of groups on implementing and evaluating clinical practice guidelines including the WHO, which is trying to implement guidelines to optimize maternal and infant health in low and middle income countries and the Canadian Task Force on Preventive Health Care.

When you are not working at St. Michael’s, what do you like to do in your spare time?

Last year, CAHO introduced readers to the Clinical Trials Stakeholders Association (CTSA) with its mandate to establish Clinical Trial Ontario (CTO).  CAHO is pleased that CTO has now been established as a legal entity with a new Board of Directors.  CTO’s vision is to increase Ontario’s market share in clinical trials, while maintaining the highest standard of patient safety.

The development of the CTSA and CTO started in 2010 with an announcement from the Ontario Government launching its $161 million Life Sciences Commercialization Strategy which earmarked $17 million for three clinical trial-related initiatives.  One of these initiatives asked for the establishment of a ‘new province-wide coordinating infrastructure to streamline administrative processes and ethics reviews across multiple clinical trials sites in order to increase the speed of patient recruitment.’

Clinical Trials Ontario is currently working with its new Board to finalize a 5-year strategic plan and to finalize seed funding arrangements with the Ontario government.  In the meantime, CAHO will continue to work with CTO to facilitate efforts to streamline research ethics reviews for multi-site trials. 

“We’re thrilled to see this initiative getting off the ground,” said CAHO Executive Director Karen Michell.  “CAHO played an active role in supporting and facilitating the work done by the CTSA.  The overarching goal of our work has been to contribute to a more attractive environment for clinical trials in Ontario so we can maximize our share of such trials which contribute to a more robust health research enterprise in this province.”

“It’s taken some time, but we’re happy to see CTO established and ready to start,” said Ron Heslegrave, Interim Executive Director of CTO.  “We’d like to thank CAHO and its member hospitals for their tireless work on this initiative.  CTO will help create a more competitive environment for clinical trials in Ontario while ensuring patients have access to innovative preventative and treatment therapies in the safest possible environment.”