2018 date to be announced in january 2018


This symposium is devoted to research and quality improvement in the Waterloo-Wellington region. It brings together local students, clinicians, professionals, and researchers who are working to improve the clinical care in our region.

This annual event allows local clinical trainees, non-clinical trainees, clinicians, professionals, and researchers to showcase their research and quality improvement work and receive recognition for their clinical and scientific excellence.

The goal of the symposium is to provide an outstanding opportunity for trainees to develop professional skills and to foster communication and exchange of ideas among new and established clinicians, professionals, and researchers from various backgrounds and interests.




To join our mailing list for the 2018 year, please click here

For more information or to contact the event coordinator, please email: wrcsymp@mcmaster.ca 



2018 lineup Coming soon

More information about CRQI 2018 will be posted shortly, please join the mailing list or check back for updates!



Clinical Research &

Quality Improvement

Symposium | 2017


Congratulations to our voter's choice winners:

  • Julia Borges(PODIUM) - Inventory of Tools in Comprehensive Geriatric Assessment in the WWLHIN

  • Ai-Leng Foong (PODIUM) - Ready or Not? Pharmacist Perceptions of a Changing Injection Scope of Practice Before it Happens

  • Julia Bickford (PODIUM) - Informing prescribing decisions and improving patient care through the Digital Health Drug Repository (DHDR)

  • Eunice Indome (Poster) - Alcohol Use in Older Adults: A Review of Drinking Risks and Alcohol Use Disorders to Inform the Development of National Guidelines

  • Paul Radkowski (Technology Innovator) - Life Recovery program


MAY 31, 2017 / McMaster Waterloo regional Campus

10B Victoria St. s, Kitchener ONTARio


Our 2017 Speakers


Joanne Man-Wei Ho


Joanne Ho is an internist, geriatrician and clinical pharmacologist who researches adverse drug events in the older individual using observational research and systematic review methodologies. She attended the University of British Columbia for her medical undergraduate degree and then completed residencies in internal medicine, geriatric medicine and clinical pharmacology at the University of Toronto. Her Masters of Science was completed at the Institute for Health Policy, Management and Evaluation during which time she participated in the Department of Medicine Eliot Phillipson Clinician Scientist Training Program at the University of Toronto. Joanne Ho recently completed a research fellowship with the Li Ka Shing Knowledge Institute through the University of Toronto Division of Geriatric Medicine and she is also an examiner with the Royal College of Physicians and Surgeons of Canada for Clinical Pharmacology and Toxicology. Joanne Ho is currently affiliated with Grand River Hospital and recently joined the Department of Medicine at McMaster University as an Assistant Professor in the Department of Medicine, Division of Geriatric Medicine. She is piloting GeriMedRisk, a geriatric pharmacology consultation and knowledge translation service for clinicians in the Waterloo-Wellington Region.


Thomas Hupel


Dr. Hupel obtained an undergraduate Honours of Bachelor of Science degree and a Masters of Science degree from McMaster University in the field of molecular biology. Thereafter he entered the Faculty of Medicine at the University of Toronto. After graduating from the MD program with honours, he completed a residency in orthopaedic surgery through the Department of Surgery at the University of Toronto. Dr. Hupel then completed a post graduate Fellowship at St. Michael’s Hospital in Toronto. Working under the supervision of Dr. James Waddell, Dr. Emil Schemitsch and Dr. Michael Mckee he received subspecialty training in the fields of orthopaedic trauma, and upper and lower extremity joint reconstruction.

Dr. Hupel relocated to the Kitchener-Waterloo area in 1999 and is presently in independent practice with subspecialty interests including primary and revision arthroplasty of the lower extremity as well as an interest in shoulder arthroscopy and shoulder arthroplasty. Dr. Hupel became the Regional Educational Leader for undergraduate orthopaedic education at the Waterloo Campus in 2012. Dr. Hupel was the Chief of Orthopaedics at Grand River Hospital and St. Mary's General Hosptial from 2010-2016. He is currently the Medical Director of Surgery at Grand River Hospital. 

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Lori-Anne Huebner

Lori-Anne Huebner is the Benefits Realization Practice Lead at the eHealth Centre of Excellence (eCE), located in the Idea Quarter of Waterloo, Ontario. Lori-Anne brings to this position an extensive background in conducting evaluation and research projects having partnered with several healthcare and community programs over the past 20 years, in both Alberta and Manitoba.   Since moving to Waterloo in 2015, Lori-Anne has become a strong advocate of using benefits evaluation to drive the adoption of digital health tools across the south west Ontario region, with her current work focusing on the development of case studies that identify the realized clinical and organizational value of ehealth solutions within workflows spanning the care continuum. Together with her colleagues, Lori-Anne recently published a benefits evaluation model and had opportunity to present on her work at the Information Technology and Communication in Health conference in Victoria, BC. She has also presented at the OntarioMD EMR Every Step conference on the usability and utility of standardized data within electronic medical records, and serves as the PI on a current research project exploring the use of narcotics data within the electronic health record (EHR) as an enabler for care decisions as it relates to the opioid crisis in Ontario. Lori-Anne is passionate about employing benefits evaluation to encourage uptake of digital health tools amongst clinicians, thereby enabling them to use the technology available to provide an enhanced quality of care to their patients.

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Lori Moran

As the System Coordinated Access (SCA) Program Manager at the eHealth Centre of Excellence, Lori Moran plays an instrumental role in improving access to care by leading the development of a fully integrated referral management strategy for the Waterloo Wellington region. Lori brings a wealth of knowledge and experience to the role, drawing from a wide-ranging history of large and complex project management initiatives within a healthcare setting. During her fourteen years at Grand River Hospital, Lori transitioned to the role of Director of Corporate Projects where she established a project management framework that enabled the organization to achieve project execution excellence through holistic, repeatable, consistent project management practices. An enthusiastic and trusted leader, Lori has a passion for using project management strategies to improve patient experience and outcomes.

 crqi 2017 Presentations


Keynote Presentations

Dr. Joanne Ho GeriMedRisk

GeriMedRisk: a geriatric pharmacology consultation and knowledge translation service for clinicians in the Waterloo-Wellington Region. GeriMedRisk is growing in our region and is an interesting topic for all who work with the elderly.

Dr. Tom Hupel with Lori-Anne Huebner and Lori Moran

Diagnostic Imaging For Orthopaedic Patients: The Problem And How E-Referral Can HelP

A new Orthopaedic eReferral platform is being rolled out in the province. This presentation will include two representatives from the eHealth Centre of Excellence to talk about this new initiative and the exciting research behind it. 

Podium Presentations

 eHealth and Common Health Information

Informing prescribing decisions and improving patient care through the Digital Health Drug Repository (DHDR)

Julia Bickford*, Lori-Anne Huebner, Ted Alexander, Mohamed Alarakhia             

eHealth Centre of Excellence

Background: Canada and the USA have the highest prescription opioid consumption in the world. Ontario had 638 opioid related deaths in 2013, and 3,241 ED visits in 2014. Increased opioid prescribing is associated with increased opioid-related mortality. Thus, better informed physician prescribing decisions are key to avoiding adverse drug events and improving patient safety. During the Fall of 2016, the Ministry of Health and Long-Term Care (MOHLTC) implemented an initiative to integrate the Digital Health Drug Repository (DHDR) through the connecting South West Ontario (cSWO) Regional Clinical Viewer, ClinicalConnectTM to further enhance the data and information (including narcotics information) currently available in the integrated electronic health record (EHR) in south west Ontario (SWO). 

Objectives: Following a benefits realization approach, the objective of this work is to understand the organizational and clinical value of the DHDR in acute and primary care settings. In addition, a larger research proposal will be discussed.

Methods: Interviews and surveys were conducted with clinicians in order to understand how the DHDR has been integrated in to clinical workflow at two early adopter sites in Guelph, Ontario (Guelph General Hospital and Guelph Family Health Team).

Results: Emergency department physicians at the Guelph General Hospital found the DHDR to help prevent medication error. A case study with a primary care physician working at the Guelph Family Health Team illustrates how the DHDR helps him prescribe responsibly.

Conclusions: The DHDR is a reliable source of narcotic information which contributes to better-informed prescribing decisions and improved patient care and safety.


Medication Review of Medically Complex Patients using Standardized Data

Kathryn Flanigan*, Jillian Bauer*

Centre for Family Medicine

"OBJECTIVES: Patients with complex chronic conditions consume the majority of health care services in Ontario.  Identification of high health service users and providing more proactive care, may reduce admissions and healthcare costs.

When data such as diagnoses are standardized, it can then be searchable. At CFFM, clinicians have the opportunity to code, in a standardized manner, over 100 health conditions.

METHOD: Using the CFFM FHT's patient database, a predictive analytics model was used to generate a listing of 132 patients who were predicted at 75% chance or greater of accessing acute care services within the following 12 months. For manageability purposes, the list was further narrowed to 103 patients 65 years of age and older who were taking five or more medications (known as polypharmacy), as increasing age and polypharmacy are also major predictors of high health service use. The list was sent to respective physicians who judged which patients would benefit from a Medication Reconciliation and Review with a clinical pharmacist.

RESULTS: To date, from 103 identified patients, 5 have died, 35 were deemed ineligible by the rostered physician (too ill, in long term care, palliative), 37 have been contacted, 15 have completed a medication review and 26 are to be contacted.  Results of the medication review are in the process of being analyzed.

CONCLUSION: Medically complex patients were identified by predictive analysis for medication reconciliation and review. In future the same technique can be used to search for complex patients in order to provide more proactive care thereby hopefully reducing potential ER visits and hospitalizations.


Mental Health Encounters in Primary Care: How Clinicians Can Use Technology to Support Evidence Based Care      

Mohamed Alarakhia, BSc, MD, CCFP; Stephanie Chin*, RPN, BSc, Dipl. HI; Lirije Hyseni*, MSc; Danika Walden, PMP, MSc

CFFM Care Innovations

Since January 2016, the eHealth Centre of Excellence (eCE) in Waterloo, Ontario has been leading project QBIC (Quality Based Improvements in Care) to enhance quality of care through EMR decision support tools that facilitate best practices in chronic disease prevention and management (CDPM). Recently, the eCE developed a Depression and Anxiety tool for the EMR to support clinicians in the screening and management of mental health with a focus on Depression and Anxiety. The tool incorporates guidelines developed by Health Quality Ontario, the Centre for Effective Practice and the Canadian Mental Health Association. 
The objective of the presentation is to demonstrate the Depression and Anxiety tool and the link with tablets for mental health assessments incorporating PHQ-9, GAD-7, SDS and LEAPS, allowing for clinicians to gather, document and reference these metrics more efficiently at point of care. We will also demonstrate how the mental health metrics and trends can be viewed and accessed through the Mental Health Toolbar, which incorporates specific elements from the Depression and Anxiety tool and gives easy access to customized patient handouts, lab requisitions and other mental health resources. The plan for evaluating the organizational and clinical benefits of the tool will also be discussed. 


Inventory of Tools in Comprehensive Geriatric Assessment in the WWLHIN

Julia Borges*, Dr. George Heckman, Jane McKinnon Wilson

University of Waterloo; Canadian Mental Health Association Waterloo-Wellington

Comprehensive geriatric assessments (CGAs) are considered the gold standard for determining a frail older adult's medical, psychological, and functional capability in order to develop an integrated plan for treatment and long-term follow-up. However, due to the heterogeneity of tools used in geriatric assessment across health professions, organizations and care settings, the effectiveness of CGAs across care settings for differing complexities of patients is largely unknown. This research surveys 20 different organizations or practitioners across the Waterloo-Wellington Local Health Integration Network (WWLHIN) in Specialized Geriatric Services, primary care and acute care to determine the tools used for assessing various aspects of an older adult's health, known as domains. Within a given domain, some organizations were not assessing at all, while others used "homemade" tools or an array of validated tools based on preferences and licensing. Overall, the vast heterogeneity of assessment and tools used among health professionals, within organizations and across organizations results in a lack of interprofessional, patient-centred care, and continuity of care. The WWLHIN must look to standardize CGA within the region in order to enable quality research and provide optimal patient-centred care for the region's growing complex geriatric population.

Practice Changes and Challenges

Evaluating change in mental health symptoms over time using the interRAI Community Mental Health instrument

Jerrica Little*, John P. Hirdes

University of Waterloo

Community mental health services can be an important resource for individuals living with mental illness. Through the provision of various types of treatments, individuals should be enabled to manage their symptoms and live safely in the community. However, the extent to which symptoms change over time after receiving community services needs to be assessed, allowing interventions to be better tailored to individual needs. The interRAI community mental health (CMH) assessment instrument is designed for clinicians providing mental health services in the community, and tracks information in several areas. By analyzing change in symptoms between assessments, an individual's progress can be reviewed, and adjustments to treatment plans can be made if necessary. CMH data was collected in the provinces of Ontario and Newfoundland from participating organizations. 881 individuals who had been assessed at least twice were included in the study sample. Time intervals between the first and second CMH assessments were separated into three groups: 0-3 months, 3-6 months, and 6-12 months. Change in various outcome areas were examined, such as symptoms of psychosis, depression, activities of daily living, cognition. Risk scales (harm to self, harm to others, and ability to care for self) were also assessed between assessments. The majority of scales demonstrated significant change for each time interval, with more positive than negative changes. However, instances where change did not occur were also observed, and are concerning for risk scales especially. By examining change in many symptoms over time, a holistic view of an individual's progress can be evaluated.


Investigation into the vision needs of refugee patients settling in the Waterloo Region             

Sarah MacIver*, Aysha Hassan OD; Alexander Hynes

University of Waterloo

Purpose: Impaired vision in Refugee populations can impact integration into a new Country.  In 2016, a referral process between Center for Family Medicine (CFFM), Reception House (RH), and WOVS was initiated to improve access to vision care for Refugees settling in the Waterloo Region. The purpose of this review is to investigate the scope of vision issues that were seen at WOVS and reflect on the benefits and barriers identified following new initiative.

Method: A review of the vision exam records from the refugee patients seen at WOVS will be done to investigate the number of patients seen as well as the scope of vision issues seen. The scope of vision issues will be divided further into refractive (spectacle) issues and eye health issues as well as the varying levels of visual impairment.

Results: 168 refugee patients were seen at WOVS between Jan 1, 2016 and Dec. 31, 2016.  The majority seen were school and working age. 1 in 4 needed glasses specifically to address reading issues yet presented with good distance vision. 1 in 3 had another eye condition that required further investigation. Data on the scope of visual impairment, as well as, barriers and successes will be presented.

Conclusions: Collaboration between CFFM, Reception House and UW Optometry facilitated referrals for f eye exams in Refugee patients. The majority of patients seen required glasses and/or additional treatment for unidentified eye conditions. Identifying vision issues early can help facilitate learning English and integration into society.


Ready or not? Pharmacist perceptions of a changing injection scope of practice before it happens

Ai-Leng Foong*, David J Edwards, Sherilyn Houle, Kelly A Grindrod          

University of Waterloo

Background: Since 2012, Ontario pharmacists have been authorized to administer the influenza vaccine. In April 2016, the Ontario College of Pharmacists (OCP) proposed to expand the Pharmacy Act to allow pharmacists to vaccinate against 13 additional conditions. The OCP held an online public consultation and invited pharmacists, members of the public, and organizations to weigh in on the proposed changes. Our objective was to explore the factors influencing how Ontario pharmacists may adopt or reject an expanding scope of practice using data from the public consultation.

Methods: We coded the responses to the public consultation in two ways: 1) sentiment analysis and 2) an integrative approach to coding using Roger's Diffusion of Innovations theory across five domains: Relative advantage, compatibility, complexity, trialability, and observability.

Results: On average, responses were moderately positive. Pharmacists most commonly mentioned relative advantages, including benefits for patients, pharmacists, physicians, and the health system. Positive responses focused on accessibility for patients, improved vaccine coverage, lower healthcare spending, and freed physician time, but cited lack of prescribing rights as a barrier to the proposed changes. Negative responses focused on increased workload, patient safety concerns, and the complexity of travel medicine.

Conclusions: The expanded immunization services are likely to be well-received by most pharmacists. Convenience and accessibility for patients were commonly cited benefits, but the changes will be only a slight improvement over the current system unless pharmacists can prescribe these vaccines. Although employers responded positively, the question remains if they will support pharmacists in a way that aligns with pharmacists' values and expectations. Decision makers must pay close attention to the pharmacy infrastructure and how this will impact uptake of these services. Recognition of this, combined with pharmacists' positive perceptions of the expanded scope, will facilitate smooth integration of this legislation into Ontario pharmacy practice.


Measuring functional change following outpatient rehabilitation using the interRAI Community Rehabilitation Assessment

Luke Turcotte*, Dr. John Hirdes

University of Waterloo

The Rehabilitative Care Alliance recently sought to develop a Minimum Data Set for outpatient/ambulatory rehabilitative care that would support evaluation and capacity planning at the organizational, regional and system levels. In response to an identified need for a comprehensive and non-population specific measure of functional change, the interRAI Community Rehabilitation Assessment (CRA) was developed. This new instrument based on validated interRAI items consists of an in-clinic assessment and a patient self-report tool to reduce assessment burden and gain the client's perspective of their own functional status and wellbeing before and after participation in a rehabilitation program. In the Fall of 2016, a pilot of the CRA was conducted with 212 patients across 10 outpatient/ambulatory clinics in Ontario. Using information collected with the CRA, this presentation will characterize the functional change achieved by pilot program participants. This presentation will also describe the psychometric properties of self-report items used to identify difficulty in the completion of instrumental activities of daily living such as meal preparation, ordinary housework, shopping, and transportation. Results from this pilot study indicate that the CRA detected significant improvement in clients' capacity to complete basic and instrumental activities of daily living. Measures of inter-rater reliability also indicate that patient self-appraisals of activity difficulty could be used in place of clinician ratings to streamline the assessment process to focus only on domains where impairment is present. Results from this work will be used to refine this new instrument and inform the development of self-report models of assessment for other patient populations.

Care in the Community for Older Adults

Development of the CHESS-Lite Scale to Predict Mortality at the Point of Home Care Entry

Chi-Ling Joanna Sinn*, Dr. Jeff Poss, Dr. John Hirdes

University of Waterloo

The Changes in Health, End-stage disease, and Signs and Symptoms (CHESS) scale is an indicator of health instability and has been shown to predict mortality and health service use. In Ontario, home care patients receiving services for an extended period are assessed regularly with the interRAI Home Care from which the CHESS scale can be calculated. Moderate or high CHESS scores may identify patients who would benefit from increased or more intensive services, more frequent reassessment, and/or advanced care planning. The current study covers the development of a"CHESS-Lite" scale from the interRAI Contact Assessment that is used to assess all patients entering the home care system. A CHESS-Lite scale with comparable predictive power as the CHESS scale could identify patients who are clinically unstable and require earlier or quicker reassessment in the short-term. The sample included all Contact Assessments linked to home care referrals initiated between April 2014 and March 2015 (n=144,070). About 7% of referrals resulted in death within 90 days of assessment. Items in the CHESS scale and additional items in the Contact Assessment were tested in bivariate and multivariable logistic models. The final version of the CHESS-Lite scale consists of seven of the 11 CHESS variables and an additional self-rated health variable. The CHESS-Lite scale was a strong predictor of death within 90 days (c statistic=0.82). Compared to 1.1% of patients in CHESS-Lite 1 who died within 90 days, one-third (33.6%) and two-thirds (68.3%) of patients in CHESS-Lite 5 and 6 died within 90 days, respectively.


An Interprofessional and Collaborative Approach to Care for Seniors with Addictions

Marilyn White-Campbell*, Jessica Wilson                              

St Joseph’s Health Care Center Guelph

Older Adults with Substance Use Disorders have multiple co morbidities including chronic mental and physical health problems are often high users of health care and emergency services. The prevalence of SUD (1999-2009) in a geriatric inpatient population (1,788 admission) admitted over a ten-year period was 11.7%. Most commonly abused substance = alcohol totaling 73.3% of the identified substance use disorders. Other SUDs were also found including sedative-hypnotics, opiates, cannabis, and tobacco. The prevalence of other SUDs was as follows: sedative-hypnotic abuse/dependence 11%, opiate abuse/dependence 2.9%, cannabis abuse 1%, and tobacco use disorder 1.4%.  (Dombrowski et al, 2016 )The Waterloo Wellington Geriatrics Network identified the need for specialized geriatric addiction services. Geriatric addictions service was established with intent to build capacity in the community and to address identified needs.

In this presentation we will discuss;

  • Program development
  • Referral Sources
  • Timely Access to Care
  • Emergency Department and Acute Care Diversions
  • Successfultransitions tolong term care


“I would hope the people looking after me know about me”: Perspectives of Persons Living with Dementia and Their Caregivers on Person-Centred Care and Quality of Care

Bryan B. Franco*, George A. Heckman, Sherry Dupuis, Lisa Loiselle, Veronique Boscart, Linda Lee

University of Waterloo

Background: Person-centred care has become synonymous with high quality dementia care but persons living with dementia and their caregivers have historically been excluded from quality improvement and assurance efforts. We explored person-centred care within the context of quality of care from their perspectives.

Methods: We present results from qualitative content analysis of interviews with thirteen participants: 9 persons living with dementia and 8 caregivers.

Results: Participants generally defined person-centred care as: care you would expect at home and all participants agreed that person-centred care is important to high quality care. Three major themes about how person-centred care impacted quality of care were identified: 1) clinicians' ability to solicit what is important to patients, 2) effective and appropriate communication to patients, and 3) patients' ability to navigate health and community resources. Clinicians' ability to solicit what is important for patients was touted as the most important theme for person-centred care. Some participants emphasized the need to self-advocate to overcome barriers to person-centred and quality care.

Discussion: Persons living with dementia and their caregivers provide valuable insights into relationships between person-centred care and quality of care that can inform quality improvement and assurance efforts. Person-centred care, as understood from the perspectives of persons living with dementia and their caregivers, is influenced by proximal and distal factors at the point of care and the health system, respectively.

Conclusion: The perspectives of persons living with dementia and their caregivers are vital to clinicians and policymakers' goal of delivering high quality and person-centred dementia care.


The Impact of Home Care Services on Same Day Emergency Department Utilization

Aaron Jones*, Andrew Costa

McMaster University

Background:  Home care patients are a large and expanding subpopulation of older adults characterized by high rates of emergency department (ED) utilization.  The relationship between ED visits and home care services is poorly understood.  This study examines the impact that home care services have on same day ED utilization.

Methods: A population-based longitudinal retrospective cohort was created of all adult home care patients in a large health region of Ontario.  The cohort included all days that a patient was available for home care service from January 1st 2015 to December 31st 2015, minus holidays and weekends.  Conditional logistic regression was utilized to explore the effect that different types of home care visits during the day have on ED visits after 5pm of the same day, controlling for temporally dependent risk factors.

Results: Patients were considerably more likely to visit the ED after 5pm on days that they had any type of nursing service [Long Stay OR 1.51 (1.39-1.63), Short Stay OR 1.48 (1.33-1.64)].  The effect was greater for non-urgent ED visits [Long Stay OR 1.91 (1.53-2.39), Short Stay OR 1.62 (1.31-2.00)]. No effect was seen for personal support, therapies, or care coordination.

Interpretation:  Home care nursing services were positively associated with same day after-hours ED visits.  The effect was persistent across patient groups and nursing service types, but absent for other home care service types. Clinical issues beyond the RN/RPN scope of practice and poor integration with primary care may be leading to higher ED utilization rates.


Assessment of practicing community pharmacists knowledge, attitudes and behaviour towards influenza vaccine hesitancy in Ontario - An exploratory study

Pullagura GR*, Waite N, Violette R, Houle SKD

University of Waterloo

Objective: The emergence of vaccine hesitancy (VH) as a barrier to vaccine uptake calls for research to better understand the challenge. The purpose of this study was to assess the Ontario community pharmacists’ knowledge, attitudes and behaviour towards influenza VH.

Methods: A cross-sectional survey was developed and refined in consultation with members of the Canadian Immunization Research Network (CIRN). The survey was distributed electronically to 5,610 community pharmacists practicing in Ontario.

Results: The survey was completed by 885 community pharmacists, yielding a response rate of 16%. Pharmacists reported encountering an average 16 vaccine-hesitants per-week during the 2015-16 influenza season. Pharmacists' self-graded knowledge on influenza: disease, vaccine and related issues across a 15-component question was consistently high. About four out-of-five pharmacists [78.3%(n=634)] recognize their role in engaging influenza vaccine-hesitants about receiving the vaccine as that of "very high" importance. They also consistently rated high confidence in addressing common vaccine concerns. However, close to two-thirds [61.6%(507)] of the pharmacists believed that 70% of all individuals getting the influenza vaccine have made their decision, prior to meeting their health professionals. Additionally, 66.3%(n=465) pharmacists stated that most individuals (70%) getting the influenza vaccine actively "ask" for the service. The pharmacists rated workflow, time and staffing as the most important barriers to effective immunization service delivery, while the quality of current immunization training and their confidence in ability to immunize were least limiting. 

Conclusion: Results suggest that community pharmacists do encounter VH in their practice. Although they recognize the importance, possess the knowledge and ability to address influenza VH; pharmacy specific operational barriers prevent them from optimally engaging with patients in this space.

Poster Presentations

P-1: The Voice of the Senior- “Please Help Me To Tell My Story Once”

Jane McKinnon Wilson, Audrey Devitt, Tiffany Symes, Cathy Sturdy-Smith*, Kathleen Purdon*, Emily Vines*

St. Joseph's Health Care Centre, Canadian Mental Health Association Waterloo Wellington and Regional Geriatric Program Central

In response to the Voice of the Senior- "Help Me Tell My Story Once" the Waterloo Wellington Specialized Geriatric Services implemented a Clinical Intake "Virtual Team" to  provide a streamlined clinical referral system  for geriatric patients in need of geriatric medicine, geriatric psychiatry; mental health outreach, and Community Responsive Behaviour Teams (CRBTs) that is robust to phase in referrals for  Intensive Geriatric Services and Memory Clinics (non-FHT). 

The Regional Geriatric Program Central provided resources and support to initiate a Specialized  Geriatric Services Clinical Intake. St. Joseph's Health Centre Guelph in collaboration with the Canadian Mental Health Association - Waterloo Wellington Specialized Geriatric Service, received WWLHIN funding to enhance the specialized geriatric services clinical intake service.

The poster presentation will share the evaluation outcomes of the following measures in response to the implementation of the  Waterloo Wellington SGS Clinical Intake Service. 
1) Enhancing access to comprehensive geriatric assessments and care planning services in the community
2) Reducing the "burden" on geriatricians, allowing them to address more complex cases; and
3) Increasing access and easier transition to community care for clients; addressing the voice of the senior to "tell my story once"

The current state; challenges and future opportunities will be provided as identified in the evaluation.


P-2: Alcohol Use in Older Adults: a Review of Drinking Risks and Alcohol Use Disorders to Inform the Development of National Guidelines

Eunice Indome*, Dr. David Conn, Ms. Marilyn White-Campbell

University of Waterloo

Objective: The drinking habits for the older adults are usually not identified as an underlying problem when they report to care facilities with other health conditions. Early intervention and appropriate drinking guidelines are needed for the elderly. This literature review was conducted to inform the development of national low-risk drinking guidelines (LRDG) for older adults in Canada. 
Method: The review involved a detailed literature search, which yielded a combined total of 180 peer-reviewed articles and grey literature from databases such as Ovid, psycINFO, scholars portal and Google scholar. 72 articles met the search inclusion criteria appropriate for this literature review, which was not limited only to Canada, and had no restriction on year of article publication.
Results: Three areas were identified as necessary for the creation of LRDG for older adults. First, the LRDG should consider the worsening effects of AUD on older adults with concurrent psychiatric conditions, drug and other substance use, medications, and weakened physiology. Second, screening allows LRDG to be an early intervention measure. In follow-up to screening, clinical management (detoxification), and treatment options were key to informing LRDG. Third, the current LRDG standard drink limits were found to be too high for older adults, especially when concurrent disorders were present, coupled with age-related health conditions. 
Conclusions: Current efforts are not sufficient to address AUD in older adults. Canada should consider standard drink labelling and set lower standard drinking limits, similar to the UK, Australia, and New Zealand. Recommendations include senior-specific drinking limits for the LRDG.  


P-3: Is There An Optimal Cut-Off MoCA Score That Can Be Used As An Indicator of Dementia? A Scoping Review

Jennifer Lee, Andrea Chen, Jason Locklin*, Linda Lee, Tejal Patel

McMaster University

Cognitive decline sufficient enough to interfere with independent functioning is required to diagnose dementia; however ascertaining functional impairment from patient history can sometimes be challenging. A threshold score on the Montreal Cognitive Assessment (MoCA), below which functional impairment is typically associated, could help clinicians better triage those with cognitive impairment who require more resource intensive in-depth assessment of functional impairment. The aim of this scoping review was to determine the empirical support for using a particular score on the MoCA as an indicator of dementia. 

The databases Embase, CINAHL, Medline, Pubmed, and PsycINFO were searched using the search strategy (MoCA OR Montreal-Cognitive-Assessment) AND (dementia) AND (diagnos*) as well as associated reference lists. Studies were included if they presented results from English-language MoCA screening of patients with a diagnosis of dementia or diagnostic criteria, and excluded if they examined impairment due to other conditions.

We identified 20 relevant studies that met the inclusion criteria. Of these, 17 presented optimal cut-off scores for dementia, ranging from 17 to 26, with a median score of 20.5 (mode=17 SD=4.8). Participants were recruited from specialist clinic settings (both for subjective cognitive impairment and unrelated geriatric issues), and population-derived samples. 

Researchers have examined optimal cut-off MoCA scores as a screen for dementia, yet these scores and the methodology vary widely. Further, no data are currently available from primary care settings. 

The research suggests a basis for applying the MoCA in this way, but there is a need for further research.

P-4: Medical Assistance in Dying: Key Policy Considerations for Long Term Care

Gerard Reuss*, Dr. Fred Mather, Connie Lacy, Lisa Sutherland

Sunnyside Long Term Care

On June 17, 2016, the federal government passed Bill C-14 which outlines requirements that patients/residents (including those who live in long term care) must meet to be eligible to receive medical assistance in dying (MAID).  Further Bill C-14 establishes safeguards that a doctor or nurse practitioner must follow to legally provide MAID in Canada.  

At Sunnyside Home, Region of Waterloo, a collaborative and proactive engagement approach was   undertaken to ensure that legislative requirements related to MAID could be met in a ethical manner.  A policy and procedure was created through extensive consultation with both internal committees and external community partners.  

To ensure familiarity with the MAID policy and procedure and to provide the greatest level of comfort possible, extensive education was provided.  In particular, hundreds of employees at Sunnyside (clinical and non-clinical) received education and were provided an opportunity to ask questions and work through case scenarios with staff from administration and social work.   

Sunnyside's MAID poster presentation will share highlights to the implementation journey and provide key information pertaining to its policy and procedure.  Important topics to be covered include, but are not limited to:  MAID eligibility, conscientious objection, capacity, consent, privacy and follow-up care for both staff and family/friends impacted by MAID.


P-5: Associations Between staffing Hours and Quality of Care Indicators in Long-Term Care: Results From a Cross-Sectional Cohort Study

Meaghan Davey*, Andrew Costa, Jeffrey Poss, Veronique Boscart

McMaster University

Objective: Staff information and resident's quality of care indicators at the unit level in long-term care (LTC) facilities.
Methods: Data were collected from administrative records and resident assessments from July 2014 to June 2015 at 11 LTC facilities (villages) comprising 55 units (neighbourhoods) in Ontario, Canada. A total of 69 registered nurses, 183 registered nurses, 858 nursing assistants (NA), and 2173 residents were included in this cross-sectional study. Practice sensitive, risk-adjusted quality indicators were described individually, then combined to create a composite score for each neighbourhood. Multilevel regression models were used to estimate the impact of staffing characteristics on composite quality scores. 
Results: NAs provided the majority of direct care hours in LTC facilities. NAs' years of experience and total care hours per resident day were significantly associated with higher quality of care.
Conclusions: The direct input of available care hours per resident day, especially that of NAs, was an important contributor to quality of care. The finding that shorter nursing assistant longevity also contributed to lower quality of care may have been related to less experienced staff contributing directly to poorer quality of care. This could have an indirect affect such that a poorly functioning neighbourhood contributed to nursing assistant's turnover. Overall, the most influential LTC staffing characteristics to resident's quality of care were total care hours and NA years of experience in LTC. 

P-6: Individuals with Sensory and Cognitive Impairments Face Additional Challenges Compared to Those with Cognitive Difficulties Alone:  Analysis of interRAI Data for Home Care and Long-term Care

N. Williams*, D.M. Guthrie, J.G.S. Davidson, N. Phillips, W. Wittich

Wilfrid Laurier University

We examined demographic and clinical characteristics among a group of older adults (65+) assessed with an interRAI instrument who were receiving home care (HC; n=291,824) or residing in a long-term care (LTC) facility (n=110,587) in Ontario. 

In each sample, individuals were separated into eight mutually exclusive sub-groups based on the presence of sensory and/or cognitive impairment (CI).  One group had no impairment, three had only sensory impairments (either hearing, vision, or a combined loss in both vision and hearing [dual sensory impairment or DSI]) and the rest had a combination of sensory and CI.  

The rate of all three impairments (i.e., CI+DSI) was 21.3% in HC and rose to 29.2% in LTC. Compared with the other sub-groups, these individuals were more likely to report loneliness, have reduced social engagements and greater functional impairment.  In both care settings, clients with CI+DSI were more likely to experience communication problems compared to clients with CI alone.  For example, HC clients with CI+DSI, compared to clients with only CI, were more likely to have difficulty understanding others (38.0% vs. 25.1%). 

Sensory and cognitive impairments are highly prevalent in both HC and LTC settings and are potentially modifiable making them an important target for interventions to reduce negative health outcomes.

P-7: Spending wisely: Home Care Assessment Cost in Ontario

Sophie Hogeveen*, Chi-Ling Joanna Sinn*, John Hirdes

University of Waterloo

Objectives: With an aging population and increased focus on home and community care, questions are raised about how best to allocate limited resources. The objective is to estimate the time and money allocated to assessment in home care relative to the amount spent on service provision. 
Methods: In Ontario, all long-stay home care clients are assessed using the RAI-Home Care (RAI-HC). The results inform the type and frequency of services in the care plan. RAI-HCs completed in fiscal years 2012/2013 and 2013/2014 were linked to a billed services record (N=288,278). Hours or number of visits for nursing, personal support, physiotherapy and eight other disciplines were aggregated from the assessment date until the next assessment or discharge. Service volumes were multiplied by region-specific costs for providing each service. 
Results: The sum of hours of assessment was divided by the sum of hours of care (assessment and services) provided. Cost was calculated in the same way. Only 1.41% of total hours or 1.56% of total cost of care was spent on assessment. In other words, less than 2% of time and money spent on home care clients was devoted to their assessment with the RAI-HC. Results were consistent across type of assessment and region. 
Conclusions: Assessment time and cost account for a small proportion of total resources spent in home care. Eliminating duplication of assessments and improving sharing of information throughout the health care system can further make the assessment process more efficient. 

P-8: The Development of Quality Indicators for Seriously-ill Home Care Clients in Ontario

Lisa Harman,* Nicole Williams, Dr. Dawn Guthrie

Wilfrid Laurier University

The objective of this research was to develop preliminary quality indicators (QIs) for seriously-ill home care clients. 
Secondary analysis of Resident Assessment Instrument for Home Care (RAI-HC) data from 2006-2013 (n=263,767) was used to develop QIs thought to be relevant to the needs of seriously-ill (SI) home care clients. SI clients were defined as having a prognosis of 6 months or less and a high level of health instability indicated by the CHESS scale. Consultations with subject matter experts (SMEs) took place to gain insight as to what was important to measure for SI clients. Client-level risk adjustment was performed on the QIs that the SMEs deemed appropriate. The rates of the created QIs were stratified across local health integration networks (LHINs) to examine regional variations across Ontario. 
A preliminary set of QIs were modified after the SME consultations were completed. A total of eight quality indicators were developed for use with the RAI-HC, two with client-level risk adjustment. QIs with the highest rates were prevalence of shortness of breath (66.2%), prevalence of falls (49.0%) and prevalence of daily pain (46.6%). The northern regions of Ontario had higher rates than the Central regions for six out of eight of the QIs, indicating that the northern regions of Ontario may be performing worse than the central regions. 
Hospice palliative care services in Ontario are undergoing a process of restructuring.  This research can assist in understanding where potential quality issues exist, which can ultimately contribute to quality improvement initiatives in this sector. 


P-9: The Impact of Prescription Medication Cost Coverage on Optimal Adherence to Hypertension and Diabetes Medications: A Repeated Cross-sectional Population-based Study

Mrs. Razan Amoud (BScPharm, MSc Student), Dr. Mhd Wasem Alsabbagh (BScPharm, PhD)

University of Waterloo

Background: Adherence to hypertension and diabetes mellitus medications is required in order to achieve optimal clinical outcomes. Medication cost can become an obstacle to adherence if patients do not have medication insurance coverage. No previous studies examined the impact of absence of insurance coverage on adherence to oral antihypertensive or antidiabetic medications in Canada. Also, the time-trend of non-adherence due to absence of medication insurance coverage has never been examined. Methods: data from the Canadian Community Health Survey cycles 2007-2008, 2013 to 2014 will be used. A provincially representative sample from participating provinces will be included (Ontario and New Brunswick). Cohort of interest will include individuals who are at least 18 years of age, have hypertension or diabetes mellitus, answered the question about prescription medication insurance coverage, and answered the question about their adherence to oral antihypertensive or antidiabetic prescription medications. Multivariate adjusted logistic regression will be fitted to estimate the odds of non-adherence among uninsured individuals with hypertensive or diabetes along with the statistical significance of this association. Conclusion: The study in progress will report the time-trend and impact of insurance prescription medication coverage on medication non-adherence to oral antihypertensive or antidiabetic medications in a representative provincial Canadian sample. It will also be able to identify any underlying factors affecting this relationship. The results of this study will enlighten researchers and policy-makers about health inequality in Canada and the need for national drug coverage policies.


P-10: Factors Influencing Prescription of Riluzole for ALS Patients in Ontario Home Care

Yong-Jin Kim*, George Heckman, Susan Horton, Christopher Perlman

University of Waterloo

To investigate factors associated with the use of riluzole in ALS patients in Ontario home care. 

A retrospective cohort study was conducted in the Ontario Association of Community Care Access Centres' Home Care (OACCAC-HC) data. Assessment records of ALS patients admitted into home care between April 1st, 2005 and March 31st, 2013, who had information on the use of riluzole were reviewed. Baseline assessment data between non-riluzole to riluzole group were compared and multiple logistic regression was used to identify the predictors influencing the receipt of riluzole. Variables included in the multiple regression analysis were: age, gender, geographical location, marital status, caregiver availability, food consumption, swallowing, falls frequency, pressure ulcers, stair climbing, stamina, CPS scale, ADL Hierarchy Scale, IADL Involvement Scale, Pain Scale, Depression Rating Scale, and Changes in Health, End-Stage Disease, Signs, and Symptoms Scale. 

Among ALS patients (501 patients on riluzole vs. 776 patients not on riluzole), older age (OR: 0.97; 95%CI: 0.96-0.98), moderate-moderate severe impairment in cognitive functions (OR: 0.19; 95%CI: 0.07-0.53), and geographical location across LHINs (Erie St. Clair, South West, Waterloo Wellington, Hamilton Niagara Haldimand Brant, Mississauga Halton, South East, Champlain, and North East) decreased the likelihood of receipt of riluzole. Marital status (OR: 1.8; 95%CI: 1.27-2.52) increased the likelihood of receipt of riluzole.

A number of important predictors for riluzole prescription have been identified in this study. Such predictors could help develop policies or systematic guidelines for improving riluzole prescription.


P-11: Overcoming Barriers to Clinical Harm Reduction Interventions

Michael A. Beazely*

University of Waterloo

Interventions designed to reduce harms associated with substance use have focused primarily on people who inject drugs. These include the distribution of clean needles, supervised injection sites such as Vancouver's Insite facility, and increased naloxone distribution through Public Health and pharmacies. There are several reasons for targeting this most at-risk group including risk of opioid overdose and the risk of infection. However, harm reduction interventions for substances that do not reach the level of the "highest risk" are less well-characterized, as are tools and knowledge to manage the overlap between illicit and medically-indicated substance use. Barriers to expanding services in this area include a lack of educational harm reduction-focused resources for health professional students, limited research on the effectiveness of harm reduction interventions, ethical issues, and time/reimbursement issues. To address the lack of educational resources in this area University of Waterloo pharmacy created basic substance use content designed for clinicians and health professional students. Using primary and secondary literature, as well as peer-to-peer (grey literature) information, we proceeded to describe epidemiology, patterns of use, pharmacology, motivations for use, subjective experiences, adverse effects, drug interactions, and special populations concerns for several substances. The outcomes of this approach include the production of materials for health professional education or continuing education, identification of potential drug-drug or drug-disease interactions between medically-indicated drugs and illicit substances, and provides a framework to identify opportunities for research into harm reduction interventions for health practitioners.


P-12: Electronic Medication Adherence Technologies: Classification to Guide Use in the Older Adults

Maheen Farooqi Bsc.(c) ; Caitlin Carter, HBA, MLIS; *Tejal Patel, PharmD

University of Waterloo School of Pharmacy

Technologies available to address medication adherence range from alarms integrated into pill boxes to cloud-based pill dispensers that allow for remote monitoring. This project aimed to systematically find and classify available Electronic Medication Adherence Technologies (EMATs) and to determine how these EMATs would impact adherence in older adults based on specific physical, cognitive and social factors.  

A Google search was conducted to identify EMATs available to Canadians. A search of PubMed, Embase, IPA and Scopus was also conducted. Each EMAT was classified by reviewing the description online or in discussion with the manufacturer.  A preliminary scale was developed to assess the impact of EMATs on adherence, based on patient specific factors (e.g. physical and cognitive limitations, complexity of medications), impact on caregiver stress, and safety.

40 of the 344 Google search results were relevant to the project. 80 EMATs were identified and classified as Automatic Pill Dispensers (APDs; n=28), Pill Boxes with Alarms (PBA; n=31), Vibrating Pill Box (VPB; n=3), Electronic Blister Pack (EBP; n=5), Reminder Alarms (RA; n=6), Clock Caps (CC; n=4), or Smart Caps (SC; n=3).  APDs, PBAs, VPBs, EPBs, and CCs were thought to "improve" adherence in older adults with cognitive limitations, "improve" caregiver stress, and "worsen" adherence in persons with physical limitations. SCs would likely "improve" caregiver stress. 

A significant number of EMATs are available to assist older adults with medication adherence. Our comprehensive EMATs list and scale is the first step to enabling clinicians to recommend an EMAT based on patient specific limitations and needs.  


P-13: Integrating Best Practices through EMR Decision Support Tools

Mohamed Alarakhia BSc, MD, CCFP; Lirije Hyseni MSc; Danika Walden PMP, MSc             

Centre For Family Medicine Care Innovation

Since January 2016, the eHealth Centre of Excellence (eCE) in Waterloo, Ontario, Canada has been leading project QBIC (Quality Based Improvements in Care) to enhance quality of care through EMR decision support tools that facilitate best practices in chronic disease prevention and management (CDPM). 
The objective of the poster presentation is to illustrate the development process for CDPM decision support tools and present early findings on benefits.  
The eCE partners with other organizations that lead research on relevant best practices, to ensure that EMR decision support tools apply the best available evidence for CDPM. Physician engagement guides the tool development process to establish support and ensure the tools meet physician needs. 

To date, the CHF, COPD and CKD tools have been developed and are being deployed through eHealth coaching sessions. The QBIC team has engaged over 270 primary care clinicians and provided eHealth coaching sessions to demonstrate tools and assist with tool integration into individual clinicians’ EMRs and workflow. 

Initial findings illustrate that the CHF tool has increased influenza immunization by 82% and improved prescribing of appropriate medications for heart failure by 10%. The majority of physicians (93%) report that the tool has had a positive impact on the quality of care they provide. 


P-14: Evaluating Perceived Barriers to EMR Adoption in Kitchener, Ontario

Chen, M.*, To, E.*, Yeung, K.*, Lo, C.

McMaster University

Electronic medical records (EMR) enable clinicians to store, retrieve and manipulate patient health information electronically. EMRs improve access to patient records, practice efficiency and billing accuracy. Canada currently lags behind other countries in EMR adoption rates, with Ontario falling below the Canadian average. This study aimed to identify perceived barriers to EMR adoption faced by Kitchener primary care practices.
A survey was generated to identify demographic information of primary care practices and potential barriers to EMR adoption. These barriers were graded using a 5 point Likert scale adopted from Gans et al.  The survey was mailed to ninety unique primary practice locations, as identified through the "All Doctors Search" on The College of Physicians and Surgeons of Ontario website. 

Results and Conclusion
Currently, thirteen surveys have been returned.  Seven practices had adopted an EMR system more than five years ago ("EMR Practices") and six practices had either not adopted an EMR system or have adopted an EMR system in the past five years ("Non-EMR Practices").  The average number of patients in the EMR Practices was 2,800 and Non-EMR Practices was 1,592.  Both groups reported the same top three barriers to EMR adoption: inability to easily input historic medical record data into EMR, technical support, and affordability.  For practices that have not adopted EMR, an additional major barrier was "lack of support from practice physicians". This study is currently in its data collection phase, and the authors are awaiting further survey responses before drawing conclusions on the data.


P-15: Playing Telephone: Understanding the state of medication decision making in growing healthcare teams in the time of electronic health records

Mercer Kathryn, Burns Catherine, Guirguis Lisa, Abidi Samina, Boersema Jonathan, Chabot Christian, Chin Jesse, Dogba Joyce, Guénette Line, Légaré France, McKinnon Annette, Waked Khrystine*, Grindrod Kelly

University of Waterloo


To study how electronic health information is shared across patients, family physicians, nurse practitioners, and pharmacies, including the types of information typically exchanged, tools that support interprofessional shared medication decision-making and best practices related to the use of Electronic Health Records (EHRs) for decision making.


We visited community pharmacies, team-based primary care clinics, and independent-practice family physician clinics throughout Ontario, Nova Scotia, Alberta, and Quebec. Research assistants collected data using an ethnographic approach including workflow observations, recordings of clinicians talking aloud while prescribing or dispensing medications, and (where possible) recordings of patient interactions clinicians related to medication therapy. We also completed semi-structured interviews with clinicians to inquire about healthcare provider experiences with medication decision making and EHRs. For data analysis, all audio recordings were transcribed, translated into English as required, and thematically coded.


We collected data at 19 pharmacies and 8 medical clinics and identified five main themes. First, the Current State of Computer Systems can support or constrain the ability of clinicians to collaborate. Second, Different Communication Expectations mean healthcare providers (primary care, pharmacy) have a limited understanding of the others' contexts around managing medication, leading to frustration in general. Third, when collaborating, clinicians focus on Task Oriented Communication (e.g., errors, fax renewals) rather than decision oriented communication (e.g., choosing the best medication). Fourth, clinicians express that they value Shared Decision Making but in practice focus on informing patients and describing options with minimal patient input, with limited awareness of the contradiction. Fifth, there is a Desire and Need for EHRs which are complete and accurate for making informed decisions.


Collaboration between community pharmacists and primary care providers is generally task-based with little opportunity for interdisciplinary shared decision making. EHRs are a potential tool to help clinicians share information. However, to improve the quality of collaboration, more attention will need to be paid to the environmental contexts within which community pharmacists and primary care providers manage medications.

P-16: E-Consultation: Building Capacity for Spinal Cord Injury Primary Care

James Milligan, Joe Lee, Cathy Craven, Dalton Wolfe, Craig Bauman

McMaster University

Introduction and Aims:  
Community care of patients with spinal cord injury (SCI) is challenging and could be improved with timely access to SCI specialists. This pilot study explored the feasibility of using an e-consultation service to link family physicians with physiatrists to improve family physician access to timely advice regarding SCI care.

Methods: Mixed methods study using questionnaires and interviews. Sixteen family physicians, and two physiatrists were recruited. Family physicians could access physiatrists using a secure e-consultation system. Following pilot testing, participants were invited to complete an on-line survey, using 5-point scales (1 = not at all, 5 = extreme positive) to rate various aspects of the service, and to participate in individual interviews to obtain their perceptions of the service.

Results: Surveys were completed by 8/16 physicians (44%) and 11/16 (61%) completed an interview). Fourteen e-consultations were completed, most frequently for bladder (n=4) and bowel issues (n=4). Mean ratings reflected that the e-consultation process was prompt (M=4.0), helpful (M=3.8), and relevant (M=3.6); physicians were moderately satisfied with the service (M=3.8). Interview analysis generated six themes: (i) improved access to SCI expertise for family physicians, (ii) avoidance of specialist referrals and emergency department visits, (iii) easy and convenient use, (iv) secured system for sharing patient information, (v) use facilitated by dedicated resource support, (vi) system (technological) constraints/limitations. 

A SCI specific e-consultation service can provide family physicians with timely access to advice not otherwise easily accessed to facilitate the management of SCI health issues at a primary care level. 


P-17: Is smartphone application-based patient feedback a good idea? “It depends.”

Ng, Denise*, MSc candidate; Wallace, James PhD; McMurray, Josephine, PhD; and Morita, Plinio, PhD

University of Waterloo

The aim of this study is to understand the types of barriers, specifically perceived risk, to smartphone-based patient experience feedback (SmartSurveys). Smartphones stand to transform the manner healthcare services gather patient experience information from patients. However, there is still limited guidance on the context and circumstances which are appropriate for patients to use their smartphones to share service experience feedback. 

Participants were asked to envision the use of MetricWire's mobile application to collect patient experience data. In-depth semi-structured interviews guided with questionnaires were conducted with smartphone owners (n=24) in order to capture their experiences, perceptions and attitudes using SmartSurveys. Individuals were also segmented based on their technical knowledge and motivation to protect their privacy. With consent, interviews were audio-recorded, transcribed verbatim and subsequently analyzed using QSR International's NVivo 11. 

Interviews and questionnaires revealed that there were few concerns regarding risks or usability of SmartSurveys application. However, three major themes regarding privacy emerged from the interviews. These themes include: recipients of information, certainty in information disclosure, and possible loss of information agency. 

The use and adoption of SmartSurveys is highly contextual and nuanced depending on the relationship between patients and their service provider. Participants stressed the need to disclose the purpose of data collection as well as how information is managed and by who. Health care providers and mHealth application developers should endeavour to inform end-users of the manner data is handled through their mobile application. Furthermore, providing the rationale for patient experience feedback will help patients comprehend how their opinions drive changes in service quality. 

P-18: Assessment of the Latest Evidence on Diagnosis, Management and Prognosis of Complex Febrile Seizures in Children

Kia Gilani, Diana De Santis, Natasha Mense-Dietrich

McMaster University WRC                                          

Febrile seizures (FS) occur in 2-5% of children aged 6-60 months old, classified as simple (<15 minutes, generalized, 1 in 24 hours) (SFS), complex (15-30 minutes, focal, >1 in 24 hours) (CFS), or status epilepticus (> 30 minutes)(FSE). Unlike SFS, there are no AAP recommendations on CFS due to inconsistent evidence (1). This poster will review the evidence for diagnosis, treatment and prognosis of CFS. 

CFS are diagnosed clinically after excluding alternate causes of seizures with associated fever (meningitis, encephalopathy). Foregoing lumbar puncture infrequently resulted in missed diagnoses, with 0.5-15% of lumbar punctures revealing CNS pathology. Postictal EEG has not proven to be useful in evaluation of CFS.

Some evidence supports use of intermittent diazepam to prevent CFS recurrence, with adverse events in 30-40% of children. However, these studies did not distinguish CFS from SFS, prohibiting a cost-benefit analysis. Zinc deficiency has been linked to FS, and supplementation reduced recurrence with little side effect. 

There is no association between CFS and attention, impulsivity, working memory,  academic, intellectualor behavioural disturbances. Development of epilepsy after CFS was greater than SFS (6-32% vs 1.04-5.4%) with focality being the strongest predictor (29.5-45%). EEG abnormalities after 10 days may predict epilepsy, particularly in those with focal CFS. 

Diagnostic use of lumbar puncture or EEG is not supported by evidence. CFS were not linked to neurocognitive decline, but were more strongly linked to development of epilepsy. Further studies are required to determine the utility of diazepam prophylaxis, zinc supplementation and EEG in prognostication. 


P-19: Development of a theoretical framework for assessment of quality of primary care medical service trips

Dainton, C*, Gorman, C, Chu, CH, Cherniak, W.

McMaster University

Objective: Short-term, primary care medical service trips (MSTs) are increasingly common among
medical professionals and trainees. We aimed to generate expert consensus on an objective, evidence based tool for assessing the quality of volunteer MSTs operating in low resource settings in low and middle income countries (LMICs). 
Methods: We constructed a preliminary framework based on the relevant literature on best practices for MSTs, and organized the relevant items into 6 major quality domains (Preparedness, Impact and safety, Efficiency, Cost-effectiveness, Sustainability, and Education), with 32 corresponding minor factors. Structured eDelphi feedback was solicited from 26 MST experts and stakeholders from across North America, recruited from four categories: public health/academics, medical professionals (clinicians, 
nurses, pharmacists), MST program coordinators, and non-medical MST volunteers. Levels of agreement
with prompts based on the minor factors were assessed on a 7-point Likert scale, and scores >2 (moderate agreement or worse) were re-distributed to panelists in Round 2 and 3 for further discussion. 
Results: There was strong agreement (mean score 1-2) on 14 of the core best practice elements of a quality MST, and moderate agreement (mean score 2-3) on a further 16 elements. Elements related to Impact and safety, and Cost effectiveness generated the most controversy. 
Conclusion: Evaluation of core best practice elements may be broadly useful to medical professionals
and trainees selecting a high quality short-term volunteer opportunity that adheres to consensus ethical
standards. Future research should solicit feedback from host communities and local clinicians, and assess adherence to these principles by actual MST-sending organizations.


P-20: A Retrospective Chart Review of Critically Ill Patients in the Emergency Department

Chan, D., Kolev, D., Lien, K., Wang, Y., & Tong, X.C.

McMaster University

Critically ill patients presenting to the Emergency department (ED) may require aggressive management. The goal of this study is to describe the types of critical care procedures performed in the emergency department and to identify the skills most commonly performed, and most pertinent to ED presentations. 
This is a retrospective chart review of patients who presented to the ED in GRH or SMGH that were 18 or older AND were registered in the ED AND were either transferred to the ICU or pronounced dead in the ED. Patient demographics, LOS, and invasive procedures done in the ED and first 24 hours of ICU admission were recorded.
Of the 334 charts reviewed at GRH and SMGH, 293 procedures were performed on 158 patients. Of the patients that required a critical care procedure in the first 24h, 86% were performed in the ED; the remaining 14% were performed in the ICU. 88% of the endotracheal intubations, 73% of the central venous lines, 33% of the arterial lines were performed in the ED. All the intraosseous lines, chest tubes, lumbar punctures, and pericardiocentesis combined constituted only 7% of all procedures. 
This study identifies the frequency critical care interventions are performed in critically ill patients admitted to the ED. Some of these procedures were infrequent and may lead to an increased risk for skill deterioration. Not only is the importance of critical care procedures in emergency medicine is demonstrated here, but the need to develop solutions to ensure skill maintenance.


P-21: Assessing the current practices and opinions of anesthesiologists in the Kitchener-Waterloo-Cambridge area regarding intraoperative phenylephrine administration during elective cesarean sections

Yu J*, Puopolo L, Latchford K

McMaster University

Introduction: The ideal regimen for phenylephrine administration during cesarean sections has long been disputed. Some studies show phenylephrine infusions can lead to more stable maternal hemodynamics and decreased rates of post-operative nausea and vomiting (PONV), whereas others show no differences between phenylephrine infusions and boluses. Our objective is to assess current practices and opinions of local anesthesiologists regarding phenylephrine administration (either as an infusion or a bolus) during elective cesarean sections.

Methods: A survey assessing practices and opinions regarding phenylephrine administration was distributed to anesthesiologists at Grand River Hospital (GRH) and Cambridge Memorial Hospital (CMH) from September – December 2016. 

Results: 12/20 and 9/12 anesthesiologists from GRH and CMH completed the survey, respectively. We found that 85.7% prefer to administer phenylephrine as a bolus. In terms of safety, 71.4% feel that both methods are equally safe, while 28.6% feel that infusions are safer. We also found that 95.2% feel that boluses take less time and effort, and 71.4% feel that infusions are costlier. When assessing other clinical outcomes, 81% feel that infusions would lead to more stable maternal blood pressures, and 61.9% feel that they are equal in terms of PONV.

Conclusions: While most respondents prefer to administer phenylephrine as a bolus rather than an infusion, many feel that both methods are equal in terms of safety and rates of PONV, and that infusions would lead to more stable maternal hemodynamics. Despite this, perceived increases in time, effort, and cost are significant barriers to local anesthesiologists utilizing phenylephrine infusions more often.


P-22: Development of Transgender Healthcare Curriculum Competencies Using the Delphi Method

Dr. Michael Lee-Poy*, Dr. Colleen McMillan

McMaster University

Introduction and Aims: Inclusion of transgender health is minimal to non-existent in current healthcare training. Little instruction is provided and training is not sufficient for healthcare providers to feel confident in addressing healthcare concerns in this population. The aim of this study is to identify core topics to be addressed in a curriculum on transgender healthcare using a Delphi Method.

Methods: Using a Delphi Method, experts were enlisted to provide input on the core competencies healthcare providers need to provide sensitive and competent transgender care. Experts included family physicians, emergency room physicians, educators, social workers, pharmacists and transgender individuals. Experts participated in three rounds of questionnaires to identify core topics to be addressed in a multi-disciplinary training module. 

Results: In the first questionnaire, our expert panel identified key topics to be addressed in this curriculum. Results were then compiled for the second questionnaire and respondents ranked on a scale of 1 to 7, with 1 representing "not important" to  7 representing "extremely important". Again, results were compiled and the top ranking topics were compiled for the expert panel to review and provide comment on. The final list of topics identified to be included in a transgender healthcare curriculum were background/context, healthcare/epidemiology context, surgical, psychosocial and resources.   

Conclusions: The Delphi Method was an effective tool in distilling the core topics healthcare providers need to know in order to provide competent transgender care. These core topics will be used for curriculum development on transgender healthcare. 


P-23: The Development of IPAGE: An Online Platform for Geriatric Education              

Jessica Ashbourne, Brendan Lew, Graham Campbell, Andrew Costa

McMaster University

The Interprofessional Passport for Geriatric Education (iPAGE) is an online program being developed and implemented at McMaster's Waterloo Regional Campus to improve knowledge about and attitudes toward the growing aging population. A needs assessment conducted with local students showed that only 30% had adequate exposure to geriatrics. 

Six pillars of geriatric education were identified based on geriatrics-related opportunities available to students. These encompass a variety of learning settings and modalities: lectures and conferences, interprofessional events, clinical encounters, volunteer or outreach, online learning, and research. 

Students will complete a pre-intervention survey. A knowledge component was adapted from the core competencies in the care of older persons for Canadian medical students by the Canadian Geriatrics Society. An attitudes component was adapted from the Geriatrics Attitude Scale. 

Students will undergo experiences within four of the six pillars. Short reflections written by participants will be thematically analyzed to further improve the passport. When all experiences are finished, students will complete a summative reflection as well as a post-intervention survey to assess change in knowledge and attitudes. They will receive a certificate of completion.

The team is working with a developer to create an online platform, and the program will be rolled out for the incoming class. We hope that following its implementation at WRC, iPAGE will be available at other campuses, other schools, and for students in non-medical health professions. This initiative will help better prepare students for careers in which they will frequently encounter and care for older adults. 


P-24: Enhancing diversity exposure at McMaster University Implementation of minority-group standardized patients in clinical skills education

David Nguyen*, Mark Xue*, Rasika Singh*, Kaitlyn Howden*

McMaster University

The population of visible minority groups in Canada will approximate 29% to 32% by 2031. However, when matched for confounders, minority-group patients received fewer recommendations for management of diseases such as AIDS, cancer, and heart disease. Cultural diversity in patients poses specific health challenges and it has been shown that cultural competency training in medical education improves patient care, patient satisfaction, and clinical outcomes.

To increase exposure levels to visible minority groups in the McMaster core curriculum by 25% by the end of pre-clerkship.

A needs assessment survey was administered to McMaster MD students regarding current levels of diversity in the core curriculum, and self-reported exposure to diverse groups during pre-clerkship. Additionally, a process map of the standardized patient (SP) hiring process was developed. 

Students' self-reported exposure indicated high exposure to White, South Asian, and East Asian populations, and low exposure to Black, Aboriginal, Hispanic, Southeast Asian, and West Asian populations. Students felt that diversity could be better integrated in tutorial (mean = 3.79, SD = 1.19), professional competencies (4.00, 1.07), and clinical skills (4.14, 1.04). As well, students felt their learning would benefit from the use of ethnically diverse SPs in clinical skills (4.14, 1.04) and SP cases that reflect diversity (4.42, 0.88). 

Preliminary findings indicate the need for increased exposure to SPs from minority groups in the clinical skills curriculum. Future work hopes to pilot SPs from visible minority groups to a clinical skills group over the course of one medical foundation. 


P-25: Using a quality improvement approach to enhance curriculum domain integration within the McMaster Undergraduate Medical Education (UGME) program COMPASS curriculum

Rosalind Bihun*, Breanne Golemiec*, Jasmine Levesque*

McMaster University

An assessment of the curriculum using the six dimensions of quality identified a quality gap in curriculum integration within Medical Foundations (MF). Using quality improvement methodology, we aim to have 100% of students surveyed rate their perceived comfort with knowledge/skill assimilation between pre-clerkship curriculum domains as "Strongly Agree" or "Agree" by the end of the pre-clerkship.

In order to identify an area of quality improvement within McMaster’s UGME curriculum, a process map was created. A needs assessment survey was administered to medical students to assess self-perceived comfort in integrating information acquired in all domains of the curriculum. 

Based on the results of the needs assessment survey, 14.8% of students fail to understand how they could apply information learned in clinical skills to tutorial cases, 7.4% do not understand how they could apply information learned in professional competencies to tutorial cases, and 18.5% of students do not understand how they could apply information learned in large group sessions to tutorial cases. Of the students surveyed, 70.3% felt that interactive tutorial cases that integrate concepts from other aspects of the curriculum furthered their learning.

Students struggle to make connections between curriculum content across curriculum domains. A curriculum change that could address this learning gap would be the implementation of one interactive tutorial case per MF. This case would require students to draw on their scientific knowledge, history taking and physical exam skills, and understanding of medical ethics.


P-26: Increasing student confidence in PBL’s consistent coverage of curricular concepts across tutorials: a quality improvement in medical education pilot project

Rebekah Baumann*, Yassmin Behzadian*, Rhys Abdeen Linthorst*, Ifrah Shah*

McMaster University

BACKGROUND: A cornerstone of medical education at McMaster University, Problem-Based Learning (PBL) enables students to take a self-directed approach to medical education. While PBL boasts of many advantages, the lack of standardization across and within tutorial groups regarding the depth and breadth of required content limits confidence and heightens anxiety amongst students.  

OBJECTIVE: The aim of this quality improvement project is to increase student confidence that the PBL process covers foundational curricular concepts.

METHODS: The proposed intervention consists of a brief case-specific checklist that will be read out loud by the tutor at the end of each tutorial and which outlines case-specific concepts that are considered key "takeaways" from the tutorial. The initial intervention will be first piloted by one Waterloo Regional Campus tutorial group and will later include all three campuses. The effect of the proposed intervention on improving student confidence will be assessed using pre and post intervention surveys. 

PRELIMINARY FINDINGS: A needs assessment survey was administered to medical students at the Michael G. DeGroote School of Medicine to assess their confidence that the PBL process covers foundational curricular concepts. 36 students, including representatives from all three years and three campuses, completed this survey. Preliminary findings suggest that students do not find current learning objectives to be comprehensive and that there is large variability between tutorial groups around the sharing of tutor-specific objectives. 

Conclusions: The incorporation of a case-specific checklist could yield significant increases in student confidence in their curricular knowledge while maintaining the self-directed aspect of PBL.


P-27: EAT (Efficacy & Attitudes of Teaching) Survey on the Consistency & Quality of Nutrition Education in Ontario-based Medical Schools

Candice Griffin & Patsy Lee

McMaster University

Malnutrition is a significant issue in Canadian hospitals, with approximately 45% of patients malnourished upon admission. Poor nutrition has negative implications on patient well-being and recovery, and further malnourishment may occur during hospitalization. The Canadian Malnutrition Task Force discovered that there is a significant discrepancy between perception and practice of nutritional assessment by physicians. The purpose of the EAT Survey is to assess medical student knowledge, perceptions and attitudes towards nutrition and patient-related malnutrition and evaluate their satisfaction with related teaching. We seek to ascertain whether the core education future physicians receive during training can be improved in order to effectively identify, assess, and manage malnourished patients.


P-28: The More-2-Eat Project: Key nutrition care changes in hospitals implementing the INPAC pathway

Valaitis, R.*, Laur, C., McNicholl, T., Keller, H.

University of Waterloo

Background/Objectives: The More-2-Eat project aims to optimize nutrition care in 5 Canadian hospital units through the implementation of the Integrated Nutrition Pathway for Acute Care (INPAC). Hospitals spent one year making positive changes to nutrition care processes, including malnutrition screening, nutrition risk assessment [Subjective Global Assessment (SGA)], food intake monitoring, standard/advanced care strategies and discharge planning. 
Methods: Hospital staff collected data from patient health records (N=3,838) to track routine nutrition care activities on the unit. Detailed patient data was collected on approximately 20 patients per month to track patients’ health and nutritional status and barriers to food intake (N=1,007). Each month, sites received feedback reports to track their progress to help stimulate and maintain positive change.   
Results: All 5 sites increased the number of patients screened for malnutrition. By the end of implementation, sites were screening 66-89% of admitted patients. SGA was not used prior to implementation. Once introduced and promoted, the number of patients at nutrition-risk assessed using SGA ranged from 12 to 70 percent. Three sites worked towards implementing food intake monitoring using a variety of strategies. Monitoring that resulted in actions to improve intake increased from 19% to 54%, 4% to 93%, and 0 to 96% in those sites. Some sites were also able to reduce the average number of mealtime barriers identified by patients. 
Conclusions: Using a variety of implementation strategies, all sites saw improvements in a range of INPAC activities. Sites are now focusing on sustainability and rolling out those changes in other units.
This research is funded by CFN (Canadian Frailty Network).


P-29: The More-2-Eat project: associations between measures of frailty and nutritional status in patients at nutritional risk

McNicholl, Tara*; Keller, Heather; Laur, Celia; Valaitis, Renata; Dubin, Joel A.; Mourtzakis, Marina; Curtis, Lori; Nasser, Roseann; Laporte, Manon

University of Waterloo

There is increasing awareness of the detrimental health impact of frailty as well as malnutrition on older adults. The purpose of this analysis was to examine associations between measures of frailty and nutritional status in a sample from the More-2-Eat project (M2E), which focuses on improving nutrition care in Canadian hospitals.

Measures of frailty were handgrip strength (HGS) and the five-meter timed walk (5m). Nutritional status was measured by the SGA. A chi-square was used to test the associations between SGA (A vs. B/C) and 5m (>6 seconds(s)) and a Kruskal-Wallis test was used to compare SGA to continuous HGS (n=276) and 5 m values (n=123).

The median HGS and 5m scores were 19.0 kg (SD=12.4) and 6.7 s (SD=6.2) respectively. Of all the patients who had an SGA assessment completed, 59% (185/316) were identified to be malnourished (B/C), and ~43% (53/123) were found to be both malnourished and frail based on walking speed. Five meter, either using the >6 s cut-point or continuous values, was not significantly different across SGA categories (A=10.3 s vs. B/C= 10.0 s). However, HGS was significantly different (p<0.026) across SGA categories (A= 19.6 kg vs. B/C= 17.2 kg). 

In this sample, HGS values were significantly associated with malnutrition. Less than 50% of those who completed HGS also completed the 5m. HGS may be a useful measure to conduct with SGA to describe frailty comorbidity with malnutrition. Future work on HGS cut-points to establish frailty levels in an acute care population are needed.   


P-30: Making the Most of Mealtimes (M3): Differences in person-centered care (PCC) delivery during mealtime eating assistance among residents living in long-term care facilities located across Canada

Sarah Wu*, Susan Slaughter, Jill Morrison & Heather Keller

University of Waterloo

Introduction: PCC can improve the mealtime experience for residents, yet practices specific to mealtimes are poorly understood. The Meal Time Scan (MTS) is a face valid and reliable instrument for assessing these interactions. Objectives: It was hypothesized that residents who require eating assistance would receive fewer positive mealtime interactions and care practices than those who do not require assistance. Methods: M3 is a cross-sectional study based in 32 long-term care homes across AB, MB, ON and NB. Mealtime practices were observed by one of eight trained assessors for 637 randomly selected residents at three meals on non-consecutive days. Observation ratings were averaged across the three meals. An Edingburgh Feeding Evaluation in Dementia Questionnaire item determined if assistance was required ("never/rarely", "sometimes", "often"). A summary score from MTS was calculated based on the ratio of positive to negative mealtime specific interactions, with higher scores indicating more positive interactions. ANOVA determined if frequency of physical eating assistance a resident received was associated with the ratio of positive-to-negative PCC interactions. Results: Almost one-quarter (23%) of residents required some level of assistance (11% sometimes; 12% often). Frequency of eating assistance was negatively associated with the ratio of positive to negative mealtime interactions [F(2, 632)=34.72, p=< 0.001; never/rarely=2.3, sometimes= 1.6, often=1.5]. Conclusions: Residents requiring more physical eating assistance received fewer positive interactions with staff compared to those requiring no assistance. Further work will examine the independence of this association and if it influences food intake. (Funding from Canadian Institutes of Health Research)


past crqi programs