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RTSO Airwaves

Spring Issue 2015


Featured in this issue:
Respiratory Therapists
Without Borders
(RTWB)
An Update

Caroline Janowski - RTWB 2014


Read the full article - page 14
Photo courtesy of RTWB

The Procurement of
Anaesthesia Volatile Agents:
an Evidence-Based Review
Leadership Report
Community RT
Research
Management Corner
Student Corner
CIHI Update
Ask aRTee

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Brampton, ON L6W 4V1
Tel: 647-729-2717/Fax: 647-729-2715
Toll Free: 1-855-297-3089
E-Mail: office@rtso.ca

www.rtso.ca

Presidents Message
Kyle Davies RRT BSc
Support for your COPD patients

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the Ontario Ministry of Health and Long-Term Care and Canada Health Infoway.

Greetings! On behalf of the RTSO Board of


Directors, I would like to welcome everyone to
the Spring Edition of the RTSO Airwaves. Spring is
upon us and as the weather gets warmer and the
days get longer well all want summer to be here
sooner! With the New Year in full swing everyone
is getting busy with work but I hope that everyone was able to take time to enjoy March break
with friends and family.
I would like to thank Shawna MacDonald and Elisabeth Biers for all of their hard work in putting together
another excellent edition of the RTSO Airwaves. Without their efforts, we would not be able to bring such
an excellent editorial to our readers.
I would also like to thank all of our Board Members and Committee Chairs as they have been diligently
working to ensure that their work plans and visions are coming together so that we, as the RTSO, are able
to continually progress the RT profession here in Ontario.
The RTSO is in full planning mode for our upcoming Annual Education Forum. With the help of the
Board and our Business Manager Stephen Laramee we have been able to secure the Mississauga Banquet
and Convention Centre, so please mark Friday, November the 13th in your calendars. We have some
exciting ideas for this years forum, which will hopefully break from tradition and provide you with the
information you need and want in an exciting and interactive manner. On that all of our members will
have received a link to a quick five-minute survey on what you want to hear at this years forum. I would
RTSO Airwaves - Spring 2015 Page 1

encourage everyone to take the few minutes to


complete the survey so we can ensure you get
what you want!
We will once again be co-hosting an annual event
in Ottawa. Last year this event was a huge success
and many thanks go out to Dave Dafoe, Sylvie
Bourbonnais, Aaron Nesom and Julie Boulianne
for their leadership around this. Im sure this year
will be bigger and better. We have secured the
Hellenic Community Centre for Thursday, October
the 29th, 2015.
Havent had the time to renew your membership
yet? Not a problem! You can continue to join the
RTSO at any time during the year and be able
to take advantage of the great value the RTSO
offers you. For example our new option to opt
into professional liability insurance. This value
add allows members to decide if taking advantage
of PL&I is right for them! In addition, all RTSO
members also receive a membership to the
Ontario Respiratory Care Society (ORCS), allowing
you members access and pricing to all ORCS
events. Your membership fees go to professional
and political advocacy campaigning around lung
health strategies, expanding the role of the RT,
research and best practice initiatives, advanced
practice bursaries, professional development
and continuing education programs, and peer
recognition awards. We always enjoy hearing
feedback from you whether youre a member or
not and would like to know what you think the
RTSO should focus on and how we can improve.
How do you feel the RTSO can best serve the RT
Community? Would you like the RTSO to provide
a brief presentation at your workplace? Please let
us know by emailing office@rtso.ca

In an effort to ensure that we do continue to serve


the RT Community and to ensure that we stay up
with the times, you can now follow the RTSO on
Twitter @RTSociety_ONT and like us on Facebook
at Respiratory Therapy Society of Ontario. Were
also continually looking at ways in which we can
make information easier and quicker to access. We
continue to investigate website enhancements that
maintain our current functionality while making
the site easier to navigate, as well as auto-sizes
wih smart devices.
The RTSO belongs to all RTs in Ontario. It is
your right to be part of a professional association
that stands up for you and your right to be heard.
In order to grow and change with our evolving
healthcare system, we as a profession need to
be engaged and collaborative with our peer
associations and key stakeholders in the MOHLTC.
Our voice, together, can move and shape our
profession so that we continue to represent what is
right for the RTs.
If you are interested in becoming involved with
the RTSO please send an email to office@rtso.ca
we thank you for your continued support to ensure
that our voices continue to be heard.
Please enjoy another great addition of the RTSO
Airwaves

Shawna MacDonald RRT


RTSO Airwaves Editor
Spring is now officially here! Temperatures have
moved from miserable to pleasant and the cold,
drab winter is transforming into promising new
life. Spring unlocks the flowers to paint the
laughing soil. ~ Bishop Reginald Heber
Spring brings with it renewal and an emerging
consciousnesssome would even say an
awakening from quiet contemplation to insight
to action. I do have to admit some similarities to
the hibernating bear this past winter, and its not
been good! The importance of our interactions
with others cannot be understated; I just read
a piece on social isolation, which stated it is
as potent a cause of early death as smoking,
at least according to the authors on the Day of
Happiness1 site. If thats indeed true, thats some
pretty powerful evidence to get out there, network
and socialize. We hope to provide you with some
opportunities to do just that in the coming months.
The transformations that Spring brings also hold
similarities to the evolution of our profession and
its growth and renewal, as we continually work to
redevelop and refine what it is to be a Respiratory
Therapist. Kacmarek2 described our profession
as one of change and innovation and in 2009
described how we are evolving into a profession

Kyle

Page 2

Editorial

RTSO Airwaves - Spring 2015

present across the continuum of care, and he was


certainly bang on with that. November 2014s
InspirEvolution captured many facets of this
evolution, but there is much more growth and
development of the profession to come. Lets strive
to harness that collective RT power and come
together to network, collaborate, share and learn.
Spring has a way of making us aware, present and
mindful. Being mindful means wed like to know
a bit more about you and your needs, as the RTSO
recognizes the need to adapt continuing education
and communication to meet those needs. Wed
love if you could participate in our survey and
help shape the future of continuing education
through the RTSO. Lifelong learning is certainly
an investment in yourself and our profession.
Now is the time for us to reflect on and question
the way that we deliver care, to engage in new
conversations, to take action and participate in
professional development to grow both knowledge
and competencies as we navigate through
change. Studies3 have shown that after 10 years in
practice there is a remarkable decrease in relevant
knowledge; this fact supports the importance of
continuous learning in remaining current in a
dynamic, technological healthcare environment.
I would like to see more of you sharing your
thoughts and experiences with us. Idea

RTSO Airwaves - Spring 2015 Page 3

International4 states that, words are not just


symbols to communicate with, they also structure
our way of thinking and make sense of our
worlds.words can limit the range of thought but
they can also expand our minds. So as the Spring
blossoms into Summer, let our professional voices
blossom and expand the ever changing healthcare
landscape, for the better!

Happy reading, and I look forward to hearing


from you.

RTSO Committee Reports

Leadership

Namaste,

Kyle Davies

References:

The Leadership Committee is currently in a review


period in order to better understand how this
committee can best serve the RTs in Ontario and
ensure that those participating are able to gain the
most from the committee and their time is used in
a valuable fashion. We as a committee need to
ensure we have a mission and vision, with clear
targets and goals so that we are kept on task and
are able to support RT Leaders across Ontario,
with whatever may come across their plate. We
want to ensure that we have the correct committee
governance, leadership and structure in place to
provide action on these goals, while working in
partnership with our other committees and taking

1. www.dayofhappiness.net
2.

Kacmarek, R. (2009). Resp Care 2009 Mar; 54(3): 375-89)

3.

Martell, B. (2010). J Med Imaging Radiat Sci 41(1), 30-38.

4.

http://idea-international.org

RRT BSc

advantage of our advocacy work and pathways the


RTSO is creating.
During this time we continue to work closely
with key stakeholders and keep lines of
communication open with Canadian Institute for
Health Information (CIHI) to ensure the Workload
Measurement Project is on track and will be ready
for the launch in April of 2016.

Correction Notice
In the winter edition of RTSO Airwaves, the student corner article entitled Discovering
Respiratory Therapy as a Student at La Cit the name of our contributor was misspelled.
The correct spelling is Stphane Lauzon and not Stephan Lauzon as published.
We sincerely apologize for any inconvenience this may have caused.

RTSO Airwaves is a publication of

and may not be copied or duplicated in full or in


part without prior permission from the RTSO.

Editor - Shawna MacDonald, RRT


Layout/Design - Elisabeth Biers
Opinions espressed in RTSO Airwaves do not necessarily
represent the views of The RTSO. Any publication of
advertisements does not constitute offical endorsement of
products and/or services.

Page 4

RTSO Airwaves - Spring 2015

Now on LinkedIn, Facebook and Twitter

Visit us for the lastest news


Share the conversation
RTSO Airwaves - Spring 2015 Page 5

RTSO Committee Reports

Committee Reports - Community Respiratory Therapy


Right: From Right to Left - Kaela Hilderley,
Kyle Davies, Yvonne Perusse, Sue Jones,
Shelley Prevost, Kelly Munoz

Community Respiratory Therapy

Below: From Right to Left - Kyle Davies, Sue


Jones, Yvonne Perusse

Ginny Myles

RRT, CRE, BHA (Hons.)


RTSO Community RT Co-Chair

Sara Han

BSc, RRT, CRE, TEACH trained


Smoking Cessation Counsellor
RTSO Community RT Co-Chair
It has been a busy few months for the
Community Respiratory Therapy group.
As noted in the last update, the group has
taken an environmental scan of the services
offered in each LHIN and have identified the gaps
that exist in all three of our pillars: Long-term
ventilation and complex airways care, long-term
oxygen therapy and chronic respiratory disease
management (primary care).
To help us formulate a work plan to take on the
work required within the pillars, several committee
members took part in an advocacy training session
and process mapping exercise in January with Sue
Jones, RRT, Quality Improvement (QI) specialist for
Health Quality Ontario (HQO). RTSO president,
Kyle Davies, also joined us for the evening. Great
discussions occurred and our group mapped
out our work plan with identified priorities. Five
priorities have been identified with key activities
and tasks. Some committee members have taken
on the leads of each priority and as a follow-up,

a discussion will take place with the larger


committee to set target dates for achieving
these tasks.
Five priorities:
1. Create Partnerships (Explore obtaining
testimonials from patients on why RT services
are needed in the community)
2. Advocacy and Awareness (of the RRT role and
value in the community)
3. System Awareness with LHINs (Create
partnerships with LHIN leads)
4. College Engagement (Work with CRTO to
help move the items that involve the College
forward)
5. Influence Curriculum (Create awareness of the
RT role in the community at the RT student
level)

Page 6

RTSO Airwaves - Spring 2015

On another note, we would like to welcome


Rebecca Whiting to the committee. She currently
works in Chatham at the Thamesview Family
Health Team (FHT) as a Certified Respiratory
Educator (CRE). We are excited to welcome her
enthusiasm to the team.
All of this great work is being accomplished by
volunteers, most of whom have full-time jobs and
busy family lives, but these RRTs deem this work
important enough to make the time sacrifice. We
are doing this with little resources besides RTSOs
dedication to better serve patients and advocate for
the profession of Respiratory Therapy in Ontario.
You can help by maintaining membership or
becoming a new member of the RTSO; visit

http:www.rtso.ca/rtso-membership-application/.
Better yet, encourage your colleagues to also
join, contribute to, and continue this work.
Please email Ginny Myles (mylesg@tvh.on.ca)
or Sara Han (shan@on.lung.ca) to learn more.

Photos courtesy of Ginny Myles.

RTSO Airwaves - Spring 2015 Page 7

Research

Research - The Canadian Respiratory Research Network: Interdisciplinary Research in Canada

Enrich and augment opportunities for


respiratory research and capacity building
Train and mentor researchers with transdisciplinary expertise who can produce
cutting-edge respiratory research and who are
in worldwide demand; and
Spearhead knowledge translation, educational
outreach and community engagement to
improve diagnosis, management, and health
outcomes of patients with respiratory disease
nationally and globally.

The Canadian Respiratory


Research Network:
Interdisciplinary Research
in Canada
Nancy Garvey RRT, MAppSc
Dr. Shawn Aaron and a team of leading respiratory
researchers from across Canada will receive
over $8 million in funding from the Canadian
Institutes for Health Research (CIHR), provincial
governments and industry sponsorships for
the Canadian Respiratory Research Network
(CRRN), implemented in 2014. It stands to make
major inroads to address many practical issues
related to respiratory disease, and integrates a
multidisciplinary team approach.
RTSO Research Committee members hope
that colleagues will be able to contribute to
the evidence being developed through the
various platforms as well as integrate the results
of CRRN research into their practice. The
following transcript of Dr. Aarons June 9th, 2014
presentation, adapted with permission, provides
a comprehensive overview of CRRN activity. For
more information, including a video of Dr. Aarons
presentation, please refer to the web-site: http://
www.respiratoryresearchnetwork.ca/

CRRN Presentation 9 June 2014


by Shawn Aaron
There are HEALTH CHALLENGES that need to
be addressed.

There are RESEARCH CHALLENGES that need to


be addressed.
Respiratory disease research in Canada is strong
but fragmented, with relatively little collaboration
between centers, across disciplines, and between
pediatric and adult-focused researchers. There is
a scarcity of robust technology platforms for
airway disease research that can support multicentered national and international initiatives.
There are declining numbers of highly trained
academic and research capable respirologists,
both for pediatric and adult patients. How will
these challenges be addressed?
The CRRN will generate synergies with other
existing research networks, and link with patient
advocates, health practitioners and policymakers
from across disciplines, to tackle the growing
public health problem of chronic respiratory
disease in Canada. CRRNs goal is to bring
researchers together across disciplines and
research themes/pillars to work in a coordinated
fashion in order to improve understanding of the
origins and progression of chronic airway diseases
in Canada. Our mission is to:
Accelerate respiratory research that has
worldwide impact on improving patient care

Page 8

RTSO Airwaves - Spring 2015

CRRN has eleven Platforms that serve as the


foundations of our overall network approach.
Research Priorities include:
Understanding the mechanisms by which
environmental exposures such as air pollution
or smoking can aggravate or directly lead to
asthma and/or chronic obstructive pulmonary
disease (COPD);
Finding biomarkers that are predictive of
outcome;
Understanding the impact of undiagnosed
airway disease; and
Mapping the natural history of mild airway
obstruction.

ADDRESSING KEY KNOWLEDGE GAPS


IN RESPIRATORY HEALTH
The following information identifies the leadership
and focus of the eleven platforms that comprise
the Network:

Imaging Platform
Dr. Grace Parraga (James Robarts Research
Institute, University of Western Ontario, London ON)
Goals: To expand use of novel CT and MRI for
COPD patient phenotypes to 4 or 5 geographical
nodes in Canada; and to enable novel pulmonary
imaging platforms across CRRN nodes and

investigators for future studies (eg. proof of


concept RCTs of novel therapies in asthma, CF or
COPD).

Air Pollution Exposure Platform


Dr. Christopher Carlsten (University of British
Columbia, Vancouver BC)
Goals: To integrate the COPD cohorts into
APELs (Air Pollution Exposure Laboratory) welldeveloped exposure model; to address key
questions of mechanism and biological plausibility
of observations linking air pollution with COPD,
connecting to public health concerns; and to
demonstrate that traffic-related air pollution
augments subclinical (biomarker) and clinical
(lung function) elements of airway disease in
smokers at risk for developing COPD.

Physiology Platform
Dr. Denis ODonnell (Queens University,
Kingston ON)
Goals: To identify the most sensitive test(s) of
peripheral airway dysfunction for earlier diagnosis
and more accurate prognosis of smokers and nonsmokers who are susceptible to airway injury; and
to support the other CRRN platforms by providing
a comprehensive physiological characterization
and phenotyping of small airway dysfunction.

Biomarker Platform
Dr. Don Sin (University of British Columbia,
Vancouver BC )
Goals: To determine novel molecular targets of
airway disease as a foundation for biomarker
discovery; and to use emerging genomics and
proteomics tools to better phenotype cohorts
and to develop novel biomarkers to predict
development and progression of chronic airway
diseases.

RTSO Airwaves - Spring 2015 Page 9

Research - The Canadian Respiratory Research Network: Interdisciplinary Research in Canada

Pharmaco Epidemiology Platform


Dr. Francine Ducharme (University of Montreal,
Montreal QC)
Goals: To use pharmacoepidemiological data to
determine if poor control of airway disease in
asthmatic preschoolers leads to increased severity
and progression of chronic airway disease in later
life; and to determine whether poor control of
asthma in pregnant mothers leads to increased
severity and progression of chronic airway
disease in their offspring.

Health Services Research Platform


Dr. Shawn Aaron (University of Ottawa, Ottawa ON)
Goals: To determine the burden of undiagnosed
airway disease (asthma and COPD) in at-risk
Canadian adults; and to determine whether early
treatment of newly diagnosed airflow obstruction
affects patient quality of life and health outcomes.

Health Economics Platform


Dr. Mohsen Sadatsafavi (University of British
Columbia, Vancouver BC)
Goals: To develop the first Canadian
comprehensive disease simulation models
of asthma and COPD in which the impact of
technologies can be evaluated; and to evaluate
the cost-effectiveness of a screening and treatment
strategy for undiagnosed airway disease at the
community level.

Basic Science & Discovery Platform


Dr. Andrew Halayko (University of Manitoba,
Winnipeg MB)
Goals: To identify markers and mechanisms of
disease origin and progression that can be targets
for novel drug and biomarker discovery for future
pre-clinical studies and network clinical trials; and
to interrogate biological specimens from human

subjects in current cohorts for comprehensive


molecular characterization.

Population Health Platform


Dr. Andrea Gershon (University of Toronto,
Toronto ON)
Goals: To conduct innovative, collaborative,
quality respiratory disease research that improves
the health of populations of people with
respiratory disease.
The Population Health Platform will make
use of health administrative databases and
other population-level data, to assist network
researchers in achieving CRRN research goals

Environmental Health Platform


Dr. Teresa To (University of Toronto, Toronto ON)
Goals: To use population-based epidemiological
data to measure respiratory health effects of
individual air pollutants and climate change;
and to identify high-risk subpopulations (age,
sex, smokers) or clusters (rural/urban living,
SES) to determine the effects of different
air pollutants and climate mixtures on the
development, exacerbations and progression of
asthma and COPD.

Cohort Platform
Dr. Jean Bourbeau (McGill University, Montreal QC)
Dr. Wan Tan (University of British Columbia)
Goals: To identify potentially modifiable risk
factors for COPD besides cigarette smoking.
CanCOLD is a prospective longitudinal
cohort study that includes > 1300 subjects
followed prospectively over years and will
serve as a resource for multiple network
studies and platforms.

Page 10

RTSO Airwaves - Spring 2015

Research - The Canadian Respiratory Research Network: Interdisciplinary Research in Canada

The CRRN Training Program

Project 2:

The CRRN has partnered with the Canadian


Lung Associations (CLA) REspiratory NAtional
Scientist Core Education and Training Program
(RENASCENT) to provide funding for Trainees.
Each trainee will receive a comprehensive
professional and research skills curriculum, as
well as a structured mentorship program with a
CRRN investigator. Funding will be available for
students, fellows and new investigators.

Air Pollution Exposure Studies: Subjects will


be safely exposed in the Air Pollution Exposure
Laboratory to diesel exhaust to determine if
traffic-related air pollution augments subclinical
(biomarker) and clinical (lung function) elements
of airway disease in smokers.

Applications for Network training positions


have been developed and will be advertised
through the CLA. The RFA for network
training opportunities (PhD, post-docs, and
Young Investigator ERLI awards) will be
posted in June 2014, with a September 2014
application deadline.
Applications for ERLI awards to be reviewed by
CLA/HSF peer review committee in Dec 2014.
Funding for trainees will start in spring 2015.

Examples of how the CRRN projects link with


platforms:

Project 1:
Identification of Undiagnosed Airflow
Obstruction in the Canadian Population: Patients
found to have undiagnosed COPD or asthma in
our Health Services Research Platform would
be further studied using advanced airway
physiology, airway imaging, and biomarkers of
airway inflammation to assess pathophysiology
and functional impairment. As well, we will
determine the health economic impact of our
screening and early treatment strategy from a
patient-based and societal perspective by linking
to the Health Economics Platform.

Project 3:
Using the Canadian Cohort of Obstructive
Lung Disease (CanCOLD) we will determine
whether the presence of small airway disease
(or bronchiolitis) is predictive of rapid decline in
lung function.
Potentially pre-clinical small airway disease in
CanCOLDcohort subjects will be diagnosed
through advanced airway imaging techniques,
advanced physiologic testing of small airway
disease, and through our biomarker discovery
platform.

Project 4:
This study intends to use
pharmacoepidemiological data to determine
if poor control of airway disease in asthmatic
preschoolers leads to increased severity and
progression of chronic airway disease in later life.
This project will link to our environmental health
and population health platforms to determine if
exposure to ambient air pollution is associated
with poor asthma control in young children.
The economic impact of asthma in preschoolers
and adolescents and healthcare delivery to this
vulnerable subgroup will be studied by the
CRRNs health economics and health services
research platforms.
CRRN will serve as a structural foundation
for network-based investigators to leverage

RTSO Airwaves - Spring 2015 Page 11

Research - The Canadian Respiratory Research Network: Interdisciplinary Research in Canada

additional funding to support network-linked


projects. CRRN will complete multifaceted studies
of airway disease in pregnant mothers, children,
adults, and the elderly through establishment of
common network research platforms. CRRN will
also complete a large-scale health services project
which will investigate the burden of undiagnosed
obstructive lung disease in Canada, along with
structured evidence-based healthcare interventions
to help reduce this burden.

PATIENT ENGAGEMENT
The CRRN will partner with the Canadian Lung
Association to ensure patient engagement in
our network.
An asthma app (called breathe) has been
developed by three co-investigators in the
CRRN Environmental Health Platform. This
initiative is being coordinated by the Ontario
Lung Association. The breathe app helps asthma
patients to keep track of their symptom controls
with electronic real time symptom diary and an
action plan. Through the app, we also push realtime air quality data to the patients to help them
modify their outdoor activities with the knowledge
of the potential adverse environmental exposures.
Patient engagement is front and center of this study.
http://www.on.lung.ca/breathe-App

KNOWLEDGE TRANSLATION
CRRN has adopted the CIHR Knowledge-toAction Cycle as the framework to guide the
development, translation and synthesis of evidence
that CRRN will produce. A key aim is to adopt an
integrated knowledge translation approach that
engages potential knowledge users as partners
in the research process. As knowledge gaps are
identified, new projects will be developed to
address these gaps by liaising with key knowledge
users (patients, families, healthcare providers)
via the Canadian Lung Association, and with our
industry and governmental partners.

Research - The Canadian Respiratory Research Network: Interdisciplinary Research in Canada

airway inflammation will be studied through the


basic science and discovery platform to validate
findings at the cellular level.
CRRN Leadership:
DIRECTOR: Dr. Shawn Aaron (University of
Ottawa, Ottawa ON)
CO-DIRECTOR: Dr. James Martin (McGill
University, Montreal QC)

Industry Contributions:

Gold Partners
GSK
Astra Zeneca
Boehringer Ingelheim

Silver Partners
Novartis

Bronze Partners
Merck

Upcoming Events from

EXPECTED END-RESULTS AND IMPACT


OF THE CRRN
In Canada, chronic respiratory diseases account
for about 6.4% of total direct annual health care
costs. 8% of adults and 16% of children younger
than 12 years of age are diagnosed with Asthma.
COPD related deaths are increasing every year
in Canada. COPD is the fourth leading cause of
mortality internationally, accounting for 3.5 million
deaths annually, and is the only major cause of
mortality that is increasing in both developed and
developing countries.

The CRRN is... 50 investigators; 20


institutions; 8 provinces.

CRRN will establish a mature research-training


Moving forward, if the breathe app is demonstrated program with graduation of new investigators,
to be effective in helping symptom control and
postdoctoral fellows and graduate students. CRRN
reduce risk of disease progression, we would
will disseminate results from our collective efforts
like to further implement and promote the
to the greater community of patients, providers,
uptake of the app and also expand the app to
and policy-makers using integrated knowledge
include the COPD population. Partnering with
translation vehicles. These participants will be
CRRN platforms to engage patients in disease
further studied using advanced airway physiology,
self-management will facilitate broad scale
airway imaging, and biomarkers of airway
implementation and knowledge translation.
inflammation to assess pathophysiology and
functional impairment. Potential mechanisms of
Page 12

RTSO Airwaves - Spring 2015

One Breath at a time: respiratory update 2015


Windsor, ON
Wednesday, May 6, 2015
5:45 p.m. - 8:30 p.m.
Serbian Community Centre
6770 Tecumseh Road East, Windsor

Spring Inspirations
London, ON
Tuesday, June 9, 2015
8:00 a.m. - 4:00 p.m.
Best Western Lamplighter Inn
591 Wellington Road South, London

A Breath in Every Direction: Respiratory Update 2015


Ottawa, ON
Thursday, June 11, 2015
8:00 a.m. - 4:00 p.m.
Algonquin College
Building T, Room T-102AB
1385 Woodroffe Avenue
For more information or to register, please go to www.on.lung.ca/orcs
RTSO Airwaves - Spring 2015 Page 13

RTWB - An Update

Respiratory Therapists
Without Borders
(RTWB)
Nepal

Option 2: Organizational representatives- By joining


the Professional Network, organizations receive
recognition on our website and a certificate of
support. Membership must be renewed annually
with a donation of any sort.
Please watch the RTWB Overview and Strategic Plan
and complete the applicable form.
a) Application for organizations (first time)
b) Application for organizations (renewal)
For any questions regarding our Professional
Network or volunteer opportunities please feel free
to email Mike at mike.iwanow@rtwb.ca

presented at an international medical conference


in Thailand this month where she talked about the
work she has been doing. Thank you Annette for
representing us well.
Nepal: Our Healthcare Education Partner -Patan
Hospital - is trending success for the second straight
month in BIPAP therapy in the ER (first in Nepal)!
Of all 15 critically ill patients that received BIPAP
therapy, none required ICU admission. What at an
amazing achievement! RTWB continues to conduct
remote chart audits to optimize usage of donated
equipment. We have also just submitted an abstract
to the CSRT for poster presentation consideration.

Dear RTSO Membership,


USA: Our newest HEP is the
Western Michigan University
where an engineering design
team is working on a bubble
NIPPV solution. A patent
pending has been placed on a
functional prototype that will
be clinically trialed this summer
in Nepal.

It is with great joy that when the RTSO asked for an update from the Respiratory Therapists Without Borders
(RTWB) I write to you. The RTSO Board from 2010 played a vital role in nurturing the idea of RTWB long before it
became a registered charity in 2014. As testament today, RTSOs fingerprints continue to be all over RTWB with 3
of our directors and 2/3 advisors being Ontario Respiratory Therapists. Its a joy to continue receiving your support
with a complementary booth at the 2015 RTSO Education Forum in November. We look forward to seeing you
then if not earlier. Below is a sneak peak at the 1st quarter update.
All the best,
Eric Cheng

3. Communications
Dear RTWB Team and supporters,
It is with your support that Respiratory Therapists
Without Borders / Inhalothrapeutes Sans Frontires
(RTWB/ISF) continues to grow. Thank you! We
continue to run as a completely volunteer run
charity to improve respiratory health through
educational advancement of local healthcare
providers worldwide.

1. Volunteer Relations Update


As a charity, established and run on 100% volunteer
efforts, your professional skills, knowledge and

expertise or organizational support is the foundation


to RTWB activities. We have two membership
options now available:
Option 1: Professionals- By joining the Professional
Network, you receive free lifetime general
membership and quarterly updates on RTWB
activities. We encourage you to check the website
frequently for different ways that you can get further
involved. Please watch the RTWB Overview and
Strategic Plan then complete the Application for
professionals.

Page 14

RTSO Airwaves - Spring 2015

Litein Hospital Africa


2. Healthcare Education Partnership (HEP) Update
For further inquiries on becoming a healthcare
education partner, please contact
wendy.castro@rtwb.us
Kenya: Annette, Project Lead for Africa, has
completed a 2 yr. deployment in Kenya. She has
been monumental in establishing partnerships
and building respiratory services there. Annette

We have reached over 1000


Likes on Facebook and
continue to look to expand our
presence on social media. If
you havent already done so, visit us on Facebook!
Please view our new organizational video on
YouTube at https://www.youtube.com/channel/
UC4DhW3K4sXTYNOAsuiXWmeQ. If you would
like to see updates on what RTWB has been up to
you can also visit our blog on our website. We have
changed our communication updates to quarterly,
so please look for our next one in June! Please
keep your eyes open for volunteer positions on our

RTSO Airwaves - Spring 2015 Page 15

RTWB - An Update

website! If you have any suggestions or would like


to get involved please feel free to email Arpita at
arpita.bhattacharya@rtwb.ca

Look forward to creating a culture of caring with you,


Respiratory Therapists Without Borders
Registered Canadian Charity (# 833885437RR0001)
ideas@rtwb.ca || www.rtwb.ca
1844.4RT.STAT

Danny Ties
Left: National NSCCM Conference
2014

TM

Unique tube holder


with comfortable design
minimizes irritation &
stabilizes trach

Sil.Flex Stoma
and TC Pads
TM

Innovative cushions
absorb pressure at
stoma sites

Below: RTWB Himalyan rescue


Nepal

4. Where are we?


In addition to finding us on the web,
LinkedIn, Twitter and Facebook, we will be
at the following events below. We would
like to thank all the societies listed above
and below for their generous support with
complementary exhibitor booth space at their
respective gatherings.
Manitoba Association of Registered Respiratory
Therapists (MARRT) - 07-08.May.2015
Canadian Society of Respiratory Therapists
(CSRT) - 21-23.May.2015
British Columbia Society for Respiratory
Therapists (BCSRT) - 01-03.October.2015
Respiratory Therapists Society of Ontario (RTSO)
- 13.November.2015

Peace,
Eric Cheng
Co-Founder & Culture Creator
Respiratory Therapists Without Borders
Registered Canadian Charity (3 833885437RR0001)
eric@rtwb.ca; www.rtwb.ca
1.778.239.9335
All photos courtesy of RTWB

We continue to expand organically based on


volunteers stepping forward to fill needs and
suggest new ideas. To find out more visit us on
www.rtwb.ca or pitch ideas online or to
ideas@rtwb.ca.
Page 16

McARTHUR MEDICAL SALES INC.


TF 800 996 6674 / P 519 622 4030
mmsi@mcarthurmecial.com | mcarthurmedical.com
1846 Concession 5 W | P.O. Box 7 | Rockton, ON | L0R 1X0
RTSO Airwaves - Spring 2015

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

THE PROCUREMENT OF
ANAESTHESIA VOLATILE
AGENTS: AN EVIDENCEBASED REVIEW
Introduction
Patient safety is a priority in providing patient
care in any healthcare setting, particularly in
the operating room. There are many issues to
take into consideration related to each patient
care intervention in order to achieve the best
processes to affect the best outcomes for
patients with minimal risk for adverse outcomes
for providers.

Submitted by
Rob Bryan, A-EMCA, RRT, AA

The Respiratory Therapy Society of Ontario


(RTSO) Research Committee recommended
the development of guidelines related
to the practice of Registered Respiratory
Therapists working as anaesthesia assistants
in operating room settings to help guide best
respiratory therapy practice. The following
document summarizes issues to be taken
into consideration in the procurement of
volatile agents used to anaesthetize patients in
operating rooms, intended to contribute to the
related body of knowledge for this intervention
that impacts healthcare provider practice and
provider and patient outcomes. This article was
reviewed by the RTSO Research Committee and
by practicing Registered Respiratory TherapistAnaesthesia Assistants and Anaesthesiologists
prior to publication.

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RTSO Airwaves - Spring 2015

Procurement strategy
for anaesthesia volatile
agents in Ontario
Volatile agents are pharmaceutical drugs available
in a liquid form that are vapourized through the
use of specialized equipment during operating
room procedures in order to provide varying
levels of sedation to patients undergoing surgical
procedures. Modern anaesthesia volatile agents
commonly used in most operating rooms are
known as halogenated ethers such as Isoflurane,
Desflurane and Sevoflurane. These agents are
generally considered to be safe and have unique
clinical benefits and characteristics used in a
variety of different patient care scenarios. Due to
the chemical nature of volatile anaesthetic agents
and the way they are dispensed and administered,
there are many considerations and hazards to both
the patient and the staff that must be considered
when establishing a volatile agent delivery system
and procurement strategy.
The procurement and purchase of anaesthesia
volatile agents in Canada requires in-depth
knowledge and understanding of the available
volatile agents, formulations, clinical use,
governmental regulations and industry
standards around safe handling, storage, applied
technologies and environmental effects to be
taken into consideration when selecting a volatile
agent and delivery system for clinical use.
Traditionally the responsibility of procuring and
purchasing volatile agents relied heavily on
the expertise and collaboration of anaesthesia
and pharmacy services to guide the purchasing
department in securing a contract best suited to
the hospitals anaesthetic volatile agent needs.

Over the past decade most hospitals have merged


their purchasing departments or joined into
a collaborative purchasing system with other
hospitals represented by a single purchasing group
or agent. The goal of this system is to combine
the purchasing power and volumes of multiple
hospitals and create an economy of scale in an
effort to secure better pricing and services for
each institution. Furthermore, in Ontario, some
hospital purchasing groups subscribe to third
party purchasing agent(s) that have a broader
purchasing influence that often extend beyond the
local and LHIN (Local Health Integrated Network)
level volumes.
There are many financial benefits from combining
purchasing strategies but there are many perils
and pitfalls both clinically and financially if all
considerations regarding the safe handling and
use of volatile agents are not well understood
or employed during the procurement process.
Hospital anaesthesia departments and operating
rooms vary in resources, physical environment,
and types of applied anaesthesia technology and
equipment in use. Unfortunately anaesthesia
volatile agent procurement is not as simple as how
much the agent cost per mL. The purpose of this
document is to provide procurement stakeholders
with an evidence-based resource to better
understand how volatile agents are used, stored and
handled in relation to formulation, environmental
and air quality control considerations, and
government and regulatory requirements.
Understanding this information is fundamental in
securing a volatile agent contract that will provide
the hospital and anaesthesia service with a system
that best suits practice and clinical considerations
while optimizing both patient and provider safety
and value.

RTSO Airwaves - Spring 2015 Page 19

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

Methodology
In order to assemble a thorough body of relevant
clinical evidence and standards that can inform
the procurement and use of anaesthesia volatile
agents, two main approaches were used: a
medical literature search with the assistance of
a medical librarian using keywords and phrases
such as: waste anesthetic gases (WAGs), volatile
anaesthetic agent formulations, and safe handling
of anaesthesia agents in the operating room;
and references to several regulatory bodies
and associations from across North America
and Europe regarding current standards and
occupational health and safety regulation
including the Canadian Centre for Occupational
Health and Safety the United States (U.S.)
Centre for Disease Control National Institute
for Occupational Safety and Health, the U.S.
Department of Labor Occupational Safety and
Health Administration, and the International Social
Security Association Section on the Prevention
of Occupational Risks in Health Care. Product
monographs and Food and Drug Administrations
information from Canada and the U.S. - were
referenced as well as web based resources from the
Canadian Anaesthesia Society, American Society of
Anesthesia and The Association of Anaesthetists of
Great Britain and Ireland.

Safety first: regulatory


considerations for
the safe handling of
anaesthestic volatile
agents

The Canadian Centre for Occupational Health


and Safety (CCOHS) defines waste anaesthestic
gases (WAGs) as anaesthesia volatile agents
that are released or leaked out during a medical
procedure, exposing health care workers to the
anaesthetic gas1.The CCOHS further describes the
health effects of WAGs in reference to the Centre
for Disease Control and Prevention (CDC) and
National Institute for Occupational Safety and
Health (NIOSH) guideline on Waste Anesthetic
Gases Occupational Hazards in Hospitals in
relation to exposure in high concentrations and
low concentrations1.
Exposure at high concentrations to WAGs can
cause the following health effects including:
dizziness, light-headedness, nausea, fatigue,
headache, irritability, depression and other effects
including liver and kidney disease2. Additionally
workers can experience impairment of cognition,
perception, judgment, and motor skills placing
themselves and others at risk1,2.
Long term exposure at low concentrations can
lead to miscarriage, birth defects and genetic
damage, and cancer among operating room
workers. Some studies have also reported
miscarriage and birth defects by operating room
(OR) workers spouses 1,2,3.
Incidental and/or accidental occupational
exposure to WAGs can and do occur in almost
every OR environment every day. It is a wellrecognized hazard in the OR work place and
is incumbent on the hospital and employer to
mitigate these risks as much as possible through
quality assurance processes established by
CCOHS including how volatile agents are stored,
handled and used. Occupational exposure to
WAGs is usually related to patient factors, practice

Page 20

RTSO Airwaves - Spring 2015

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

related factors and applied anaesthesia


technology related factors. Patient related
factors include leaks around the mask and/or
artificial airways and the offsetting of gases
from a patient during the emergence phase
of gas anaesthesia. Practice related factors
include priming the breathing circuit with
volatile agents prior to applying to the patient
during the induction phase of anaesthesia,
not turning off the vapourizer when fresh gas
flow is activated and the breathing system/
ventilator circuit is not applied to a patient.
Anaesthesia technology related factors
include leaks in the anaesthestic gas machine
(AGM) and breathing system, malfunction
in the gas scavenging system, and leaks and
spills during the refilling of the vapourizer,
particularly with volatile agent bottles that
do not use an integrated fused filling system
or closed circuit filling system 1,2,4,5. The
type of vapourizer and filling system in use is
one of the main considerations that should
directly influence the procurement strategy of
anaesthesia volatile agents and occupational
health and safety in the OR.
There are many established guidelines and
evidence based practices adopted by CCOHS
that guide and mandate quality assurance
programming to mitigate OR pollution and
optimize air quality. This includes:
1. Regular air quality monitoring by a person
trained in environmental and air quality
control measurements
2. Using best practices when handling
anaesthesia agents
3. Regular maintenance of applied
anaesthesia technologies
4. Maintenance, validation and compliance
to Canadian Standards Association (CSA)
RTSO Airwaves - Spring 2015 Page 21

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

standards related to OR heating ventilation air


conditioning (HVAC)
Furthermore the use of non-fused open style
vapourizer refilling systems must meet NIOSH
and CCOSH standards for handling hazardous and
volatile materials including the use of ventilation
hoods and/or closets when refilling vapourizers.
In addition to Canadian Occupational Health and
Safety standards, accreditation criteria for Ontario
hospitals include compliance with Accreditation
Canadas Qmentum Program that follow the
Institute for Safe Medication Practices Canada
(ISMPC) guidelines in the safe handling and
storage of anaesthesia gases 1,6.
The rest of this document will be focused on
clinical considerations, regulatory standards and
requirements as it relates to anaesthesia gases
and formulations, vapourizers, bottles and filling
procedures, and operational costs and value
adds as it relates to procurement of anaesthesia
volatile agents in the Canadian and Ontario
healthcare market.

Filling systems: open


versus closed or
fused bottles
There are many different vapourizers and filling
systems available in the market today. Depending
on the generation and model of the anaesthestic
gas machine and the type of vapourizer in use
an open refilling system or a closed/integrated
fused bottle refilling system may be employed.
There are distinct refilling procedures and safety
advantages of the closed-integrated fused
bottle refilling system over the open refilling

systems that directly impact OR pollution and air


quality control as well as logistics and resource
management factors. The interface of the volatile
agent bottle and the vapourizer are different
between pharmaceutical manufacturers and are
usually unique in design and patent protected.
Understanding the type of vapourizer refilling
system in use is imperative in securing a volatile
agent contract. One must know the type of
vapourizer in use to ensure the anaesthestic
agent and adaptor system used for refilling are
congruent.
Open refilling systems are generally referred to
as Pour/Funnel fill and Keyed fill. These systems
require the end user to remove a cap and screw an
adaptor onto the threaded neck of an anaesthestic
agent bottle and refill the vapourizer using a
prescribed or specific method to reduce leakage
and spills during refilling7.
Pour fill system also known as a funnel or spout
filling system is the oldest system and is not
commonly seen on most modern anaesthesia
gas machine systems (see fig 1). It is simply an
open spout or funnel on the vapourizer in which
the contents of the agent bottle are simply
poured into the opening of the vapourizer. It
does not require an agent specific interface with
the vapourizer and is vulnerable to user error
by allowing the wrong anaesthesia agent to be
filled into the wrong vapourizer. This system
is also prone to accidental spills and leaks and
agent fumes and vapours always escape into the
ambient air when refilling. It is the least desirable
refilling system from an occupational health and
safety risk management perspective. When using
funnel/pour fill systems the vapourizer should be
removed from the AGM and OR and brought to
vented hood or closet for refilling1,2. Depending

Page 22

RTSO Airwaves - Spring 2015

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

on the model and type of vapourizer system in


use the vapourizer must be placed in a locked
or transport position during transport to ensure
there is no leakage or spills in the event the unit
is dropped or tipped over when moving the unit
away from the anaesthestic gas machine and out
of the OR. Transporting the vapourizer out of the
OR also introduces a potential spill or leak hazard
in an area that may not have the same level of
heating ventilation and air-conditioning (HVAC)
standards as an OR. Additionally threaded fill
adaptors caps and attachments can come loose
if not secured properly causing the agent to leak
or escape while in storage or during transport.
The pour or funnel system also requires additional
considerations including hidden costs related
to the need for a vented hood or closet if your
OR does not have such facilities. The refilling
procedure is labour intense and vulnerable to
handling errors and increased pollution risks.

Figure 1: illustration of a funnel filling system7


The key fill system was introduced to reduce
the risk of filling the vapourizer with the
wrong agent and to allow for vapourizer
refilling to be done in the areas where
the anaesthestic is being delivered8. This
system is much safer than the funnel fill
system and eliminates the need to transport
vapourizer in and out of the OR to be refilled. The
key system employs a volatile agent bottle adaptor

with an interface or tip that fits specifically into


to a corresponding vapourizer inlet port with a
congruent interface (see fig 2)7. The concept is
the same as a key and lock. This system allows
for refilling of the vapourizer in the OR but must
follow a prescribed procedure or leaks and spills
can occur from overfilling and back pressure. The
other limitation to this system is that the user is
still required to unscrew a cap from the agent
bottle and screw on the key adaptor during which
vapours escape into the air. Additionally the
risk of spills or leaks during uncapping and user
manipulation of the keyed filling adaptor onto
the bottle remains and can result in accidental
occupational exposure or a major spill hazard.
CCOHS recommends that this procedure is done
under a vented hood or closet, which the clinician
still has to leave the OR to prepare and replace
the agent bottle when emptied. If the key adaptor
is not installed properly the adaptor can be
misaligned with the threads on the neck
of the bottle and can slowly leak while
in use or in storage in the OR. Incidents
have also been reported of the wrong
key adaptor being attached to the wrong
volatile agent bottle allowing for the
vapourizer to be filled with the wrong
anaesthestic agent24. The key fill adaptor is
a huge improvement over the pour/funnel
system but it not a flawless system.

Figure 2: illustration of a keyed filling system7

RTSO Airwaves - Spring 2015 Page 23

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

Closed circuit refilling systems or integrated


fused filling adaptors are considered best
practice and the preferred method for
handling and storing volatile agents and
filling vapourizers by CCOHS1. This system
employs a volatile agent bottle that has
a vapourizer adaptor fused to the neck of
the bottle that is agent specific and only
interfaces with a corresponding filling
connection or port on an agent specific
vapourizer (see fig 3). The integrated fused
adaptor on the agent bottle uses a seal and
a spring loaded valve designed to open and
release the volatile agent when it is engaged
or pushed into the spring loaded filling port
on the vapourizer (see fig 4). As the fused
bottle adaptor is pushed into the vapourizer
filling port, counter pressure is applied to the
aligned spring loaded pins on both the valves.
This creates a seal and opens a direct channel,
allowing for the contents of the bottle to
empty into the vapourizer without any
volatile agent exposure to the user or leaks
into the air. When the pressure on the bottle
is released, the pins return back to the close
position engaging the valve on the fused
bottle adaptor and no more agent is allowed
to leave the bottle. Simultaneously, the pin in
the vapourizer filling valve closes preventing
any leaks or vapours from escaping out of
the vapourizer. Therefore the system remains
closed throughout the filling procedure
avoiding and minimizing any spills and leaks.
Once filling is complete, a threaded cover/
cap is screwed back onto the integrated
fused bottle adaptor to protect the interface,
and the vapourizer plug adaptor is put back
into the vapourizer filling port. There is no
preparation or manipulation of the bottle and
adaptor required by the clinician and there
Page 24

RTSO Airwaves - Spring 2015

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

is no need to leave the OR to access a ventilation


hood or closet when handling the agent. Since
the adaptor is fused by the manufacturer and the
interface is specific to the drug and corresponding
vapourizer, inadvertent filling with the wrong
volatile agent has been eliminated.

Figure 3: Picture and illustration of closed


circuit filling adaptor or integrated fused
filling adaptor. SEVOrane picture courtesy
of AbbVie Corporation. Permission to reprint
patent schematic diagram granted by AbbVie
Corporation.
Most governing bodies and associations from
around the world including CCOHS, NIOSH, OHSA,
ISSA (International Section on the Prevention of
Occupational Risks in Health Care), the Swedish
Work Environmental Authority, and the CAS
(Canadian Anaesthesia Society), ASA (American
Society of Anesthesia), AESOP (OR Nurses
Association of Portugal), ORNAC (Operating Room
Nurses Association of Canada) all recommend
vapourizers are to be refilled in a well ventilated
area utilizing a system that reduces the risks of leaks
and spills as much as possible1,2,4,9,10. In Canada,
CCOHS, CAS and ORNAC recommend using an
anaesthesia agent with an integrated fused filling
adaptor as the preferred method and system and
the use of ventilation hoods when refilling with
standard bottles that do not use an integrated

fused filling adaptor1,9. In comparison the integrated


fused filling adaptor/closed circuit filling system is
the safest in the market place from an Occupational
Health and Safety perspective, eliminates refilling
error, optimizes patient safety and is best practice
for air quality assurance and OR pollution control.

Figure 4: Picture of closed circuit filling adaptor or


integrated fused filling adaptor. Notice the inlet
ports on the vapourizers are different (specific to
the agent).

Volatile Agents:
Formulations and
Packaging
There are three anaesthesia agent pharmaceutical
providers in todays Canadian health care market.
AbbVie (formally Abbot), Baxter Corporation and
Piramal Healthcare. All produce and sell modern
halogenated volatile agents - particularly isoflurane,
sevoflurane and desflurane.
Isoflurane is a halogenated methyl ether12 and is
produced and sold by Abbvie, Baxter and Piramal.
It is less expensive than sevoflurane and desflurane
but its clinical use and appeal has waned due
to its association with cardiac steal in patients

RTSO Airwaves - Spring 2015 Page 25

with aortic stenosis and reflex tachycardia from


systemic vasodilation11.12. It is also irritating to
the airways and used for maintenance of general
anaesthesia and not used for the inhalational
induction of general anaesthesia13. There is no
discernable difference in formulation between
manufacturers. Isoflurane is highly soluble in
blood and has the longest emergence time and
potential recovery room length of stay. Desflurane
and sevoflurane emerged into the market after
Isoflurane as an alternative halogenated ether
offering more clinical benefits with less side effects.

Sevoflurane is a halogenated fluoromethyl ethyl


ether that is colourless and has a sweet odour
making it ideal for inhalational inductions and it is
also safe for all ages11,12. Solubility of sevoflurane
in blood is slightly higher than desflurane but
markedly less than isoflurane. Sevoflurane is the
most commonly used halogenated volatile agent
and is produced and sold in a highly competitive
market worldwide. It was first manufactured
by Maruishi Pharmaceutical Company for the
commercialization and clinical use of sevoflurane,
initially in Japan in 1990.

Desflurane is marketed as Suprane in Canada and


is solely produced, sold and patent protected by
Baxter. Desflurane is a fluorinated methylisopropyl
ethyl that is colourless and has a pungent odour
that can be irritating to the airway11.12. As such
generally it is used only for the maintenance
of general anaesthesia and not used for the
inhalational induction of general anaesthesia13.
Desflurane is less soluble in blood compared to
sevoflurane and isoflurane suggesting shorter
emergence from inhalational anaesthesia and potential
shorter stays in the recovery room (see table 1)12.

In 1992, Abbott Laboratory (now known as


Abbvie) obtained the license and in 1995 it was
commercialized in the United States14. In 2006
and 2007 generic forms of sevoflurane were
introduced into the market by Baxter Healthcare
and Minrad International (also known as Piramal
in Canada). In Canada, the original formulation
of sevoflurane is sold by Abbvie as SevoraneAF
and the two generic brands are sold by Baxter as
PrSevoflurane and by Piramal as SojournTM. There
are distinct differences in formulation and how
the agents are manufactured that should be taken
into consideration. Both Canadian and American
drug regulatory agencies have deemed the
generic brands therapeutically equivalent to the
original formulation
but there have been
reported differences
between the

Table 1: Human tissue and Blood Gas Partition


Coefficients at 37C (12)

Originally published
[Edmond I. Eger, II, MD,
Characteristics of Anesthetic
Agents Used for Induction
and Maintenance of General
Anesthesia, Am J Health
Syst Pharm. 2004;61(20) ]
[2004], American Society of
Health-System Pharmacists,
Inc. All rights reserved.
Reprinted with permission
(R1501).

Page 26

RTSO Airwaves - Spring 2015

formulations that has triggered a highly contested


debated regarding the stability and degradation
of the products13-19. The original formulation used
by Maruishi and Abbot (Abbvie) used a single
step method to manufacture sevoflurane with
300-400 ppm water added acting as a Lewis acid
inhibitor. The generic forms of sevoflurane from
Baxter and Piramal uses a multistep method and
does not supplement their formulation with water
or a Lewis acid inhibitors13. There is some natural
occurring water in the generic formulations but is
significantly lower than the original formulation
(approximately 130-65ppm in the Baxter brand
and less than 65 ppm in the Piramal brand13).
Sevoflurane, when exposed to certain oxidizing
contaminants, forms Lewis acids causing the
volatile agent to further degrade into hydrogen
fluoride (HF)13,14,16. HF is toxic and highly corrosive
to human tissue and can corrode, damage and
destroy vapourizers20. There have been several
incidents of sevoflurane degradation resulting in
recalls and damaged equipment but no reports of
negative outcomes in accidental human exposure
during inhalational anaesthesia21.
In 1996 Abbot (Abbvie) experienced a recall
related to bottled sevoflurane, reported to be
cloudy with a pungent odour. Investigations
revealed high acid levels and HF in the bottled
product as a result of Lewis acid (iron oxide)
contaminant from a rusty valve on a bulk shipping
container. The partially degraded sevoflurane
was then packed in glass bottles triggering a
cascade reaction with the silicon dioxide in the
glass. Abbot responded by adding 300-400
ppm water to their formulation as a Lewis acid
inhibitor, removed all components of Lewis acids
from manufacturing and shipping equipment

and changed their glass bottle to a polyethylene


naphthalate (PEN) container13. Since then the
Abbvie formulation has not had any more recalls
related to Lewis acid degradation.
In 2006, Penlon issued a massive recall of its
Sigma Delta vapourizer distributed by Baxter (a
vapourizer that was already in use with the Abbot
original sevoflurane formulation). Investigations
concluded that a Lewis acid reaction occurred
with the metal surfaces or other materials in the
vapourizer to the Baxter sevoflurane causing the
sight glass and the filling port shoe to degrade15,19.
There were no reports of patient harm but this
incident demonstrated that despite best practices
being maintained during manufacturing and
shipping of the generic low water formulation
there are clinical factors that can introduce
Lewis acid contaminants and cause product
degradation16.
In April 2014 Piramal issued an urgent drug recall
on seven lots of its generic brand of sevoflurane
due to retained material not meeting the Acidity/
Alkalinity specifications as set forth in the USP
monograph for sevoflurane from suspected Lewis
acid degradation22,25,26.
Baxter and Piramal both state their products do
not breakdown in the containers and transfer
equipment as per self-proclaimed use of best
manufactures practices but have both faced
sevoflurane degradation and recalls. Abbvie has
chosen to protect its product from degradation by
adding 300-400 ppm of water to the SevoraneAF
brand and removed any source of potential
Lewis acid reactions including changing its
bottle from glass to a polyethylene naphthalate
(PEN) container.

RTSO Airwaves - Spring 2015 Page 27

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

Packaging of sevoflurane is another consideration


when selecting an agent. The ideal container
should be free of Lewis acid contaminants,
transparent to be able to view the contents
for clarity or debris and be able to maintain its
integrity, and not break if dropped. All three
forms of sevoflurane in Canada use different
materials for their containers or bottles. Abbvie
uses a polyethylene naphthalate (PEN) container,
Baxter uses an aluminum container lined with an
epoxyphenolic resin, and Piramal uses a type III
amber coloured glass container. (see fig 5)
Abbvie originally sold sevoflurane in a type III
amber coloured glass bottles but now distributes
SevoraneAF in a PEN bottle. It was later
discovered that the silicon oxide in the glass
contributed to HF formation as part of a cascade
reaction from Lewis acid contaminants leading
to a recall in 1996. Abbvie (Abbot) responded
by replacing the glass with a transparent plastic
bottle made from polyethylene naphthalate
(PEN) which they patent protected. The Abbvie
PEN bottle is laboratory tested and a very strong
polymer that can be dropped from a 1 meter
height without any compromise to the container.
Laboratory testing focusing on the integrity PEN
containers revealed the container did not leak
any vapour CO2 over a 24 month period and
scanning electron microscopy showed no flaking
or cracking of the polymer when in contact with
sevoflurane13.
The Baxter brand PrSevoflurane is packaged in a
non-transparent aluminum container that is lined
with a flexible epoxyphenolic resin to protect the
sevoflurane from coming into contact with the
aluminum and any potential aluminum oxide
that may trigger a Lewis acid reaction. Potential
concerns have been published regarding potential

exposure to aluminum oxide contaminants


occurring during the production of the container
as well as sevoflurane acting as an organic solvent
and could leach polymer components13. The
liquid sevoflurane inside the aluminum container
cannot be seen or inspected for clarity or debris.
The aluminum canister is strong and shatter proof
when dropped from a 1 meter height but can
deform compromising integrity of the container.
With the concern that if there is damage or dents
found on the aluminum container, does this imply
compromise to the resin lining on the inside of the
container. Since the container is not transparent
its contents cannot be visually inspected. The
question now becomes disposing the bottle and
its contents due to visual compromise of the outer
structural integrity of the container versus risking
using a product that may be compromised.
The Piramal sevoflurane container is USP type
III amber glass. This is a product that was used
by both Abbvie and Baxter for years prior to
both companies redesigning the containers
and switching to alternate materials. Minrad
(Piramal) uses the glass bottle based off their
own assessment and position that potential
extractables can occur from polyethylene
terephthalante (PET) and polyethylene
naphthalate (PEN) and type III glass has no
extractables and in their experience the glass
bottle has not contributed to any degradation of
product23. This assertion in the APSF newsletter in
fall of 2007 was published long before the recent
recall in 201422 and an FDA Form 483 review in
201325,26. The Piramal container is transparent
and allows for visual inspection of the contents
of the bottle. The glass is strong but not fracture
or shatter proof and can break if dropped or
mishandled introducing a significant spill hazard
and occupational health and safety risk.

Page 28

RTSO Airwaves - Spring 2015

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

Figure 5: The left picture is the Piramal


Brand SojournTM, middle is SevoraneAF from
Abbvie and the picture on the right is the
Baxter brand PrSevoflurane
The controversy is not that Lewis acids exist
or HF is a result of sevoflurane degradation
but how sevoflurane is prepared, handled,
packaged and stored to protect it from
oxidizing material that lead to product
degradation. These recalls highlight the
unique chemical nature of sevoflurane in
comparison to other halogenated ethers in
which degradation and instability can be
caused from any number of factors ranging
from manufacturing and shipping to handling
and use.
While the debates of sevoflurane stability and
best practices rage on in the industry, the
procurement of anaesthestic volatile agents
is a complex process with many factors to
consider. Securing a volatile agent contract
that best meets an institutions needs must
include consideration to the safe handling
of anaesthestic gases, knowledge of applied
anaesthesia technologies in your clinical
setting, compliance to occupational health
RTSO Airwaves - Spring 2015 Page 29

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

and safety standards and should include using best


practices in handling, storing, and use of volatile
agents and vapourizers. As well, understanding
the differences between volatile agents including
clinical application and formulation, to ensure your
volatile agent system is clinically compatible and
occupationally safe.
Based on current evidence and occupational
health and safety standards and regulations, the
following are suggested recommendations and
best practice considerations when developing a
strategy for the procurement and use of volatile
anaesthestic agents:
1. Ensure your anaesthesia delivery system is well
maintained including the vapourizer system,
scavenging system with regular preventative
maintenance of the gas machine and breathing
system.1,2,4,5
2. Ensure there is a quality assurance program
in place to monitor air quality in the OR and
recovery room by a person specially trained in
air quality monitoring and pollution control,
such as an environmental hygienists.1,2
3. Ensure the vendor/supplier you choose has
an anaesthesia agent bottle adaptor that
can interface with your style of vapourizer
(some companies will supply a vapourizer on
consignment if you do not have a congruent
vapourizer system).
4. Ensure the interface between the anaesthetic
agent bottle and the vapourizer is agentspecific to avoid accidental filling of the
vapourizer with the wrong agent.1
5. The use of a closed circuit filling system (also
known as an integrated fused filling adaptor)
is considered the preferred method by CCOHS
and considered the most economical and safest
from an operational and occupational health
and patient safety perspective1.

6. CCOHS recommends open refilling systems to


be in a vented hood or closet while uncapping
and attaching key fill adaptors onto the agent
bottles and during refilling of pour/funnel fill
vapourizers.1
7. When considering the cost of volatile agents
and open versus closed circuit filling systems
include related costs such as human resource
needs to support a refilling system that requires
staff to attend to the vapourizer or bottle
outside of the OR, cost of adding resources/
facilities such as vented hood or closet if none
exist in the OR and potential costs if the OR has
to be shut down due a massive spill.
8. Consideration to formulation is becoming
more relevant particularly for Sevoflurane as
more product recalls reveal many influencing
factors ranging from manufacturing processes
to storage and agent container maintenance
and materials. Current research and evidence
suggests that a formulation of Sevoflurane with
a higher water content offers more stability
and buffer against degradation and potential
reactions to Lewis acid contaminants.13-21
9. The ideal bottle to store volatile agents is
unbreakable, transparent, will not react with
the agent, leak proof, and offers an interface
that minimizes spills and is agent specific to
eliminate agent-vapourizer filling errors.
10. One should also consider value adds such
as consignment vapourizers that can save
thousands of dollars per OR in capital costs,
CME programs and in-services.
The procurement of volatile agents for anaesthetic
use in hospitals and clinics includes multiple
considerations that can significantly impact
patients as well as providers in operating room
settings. In order to include all of the due
considerations, a recommended strategy in

Page 30

RTSO Airwaves - Spring 2015

The Procurement of Anaesthesia volatile Agents, an Evidence-Based Review

procuring a volatile agent contract is to assemble


a team of stakeholders and experts (pharmacy,
anaesthesia, purchasing and procurement
specialists, and management/leadership).
Contributing their unique perspective will help
ensure the hospital, department and/or clinic
needs are met, best value is obtained and that
the best outcomes for patients and providers are
achieved safely and in compliance with regulatory
mandates and occupational health and safety
standards.

14.

15.

16.

17.

References:
1.

2.

3.

4.

5.

6.
7.

8.

9.
10.

11.

12.

13.

Canadian Centre for Occupational Health and Safety (CCOHS). Waste


Anesthetic Gases, Hazards of. April 2002, updated June 13th, 2012.
http://www.ccohs.ca/oshanswers/chemicals/waste_anesthetic.html
National Institute for Occupational Health and Safety (NIOSH)
Publication No. 2007-151: Waste Anesthetic Gases-Occupational
Hazards in Hospitals. http://cdc.gov/niosh/docs/2007-151/#c
Bovin JF (1997). Risk of spontaneous abortion in women occupationally
exposed to anesthetic gases: a meta-analysis. Occup Environ Med
54:541-548
International Social Security Association (ISSA), International Section on
the Prevention of Occupational Risks in Health Services; Safety in the
use of anesthetic agents; ISSA Prevention Series No 2042 (E)
OSHA, US Department of Labor, Occupational Safety and Health
Administration; Anesthetic Gases: Guidelines for Workplace Exposures.
http://www.osha-slc.gov/dts/osha/anestheticgases/index.html
Standards, Accreditation Canada. Managing Medications. http://www.
accreditation.ca/programmmes-d-agrements/qmentum/les-normes
Michael P. Dosch CRNA PhD, The Anesthetic Gas Machine (updated July
2012), retrieved Jan, 2015 from http://www.udmercy.edu/crna/agm/05.
htm
Ronald D. Miller, Lars I. Eriksson, Lee A Fleisher, Jeanine P. WienerKronish, William L. Young, Millers Anesthesia Seventh Edition, pages
687-689, published by Churchill Livingston 2010
ORNAC. Recommended Standards, Guidelines, and Position Statements
for Perioperative Registered Nurse Practice. Revised August 2003
Swedish Work Environment Authority, Anesthetic Gases- Provision of
the Swedish Work Environment on Anesthetic Gases , together with
General Recommendations on the Implementation of the Provisions,
Guidance on Section 13, Jan 2001, retrieved Feb 2014 from http://www.
av.se/document/inenglish/legislations/eng0107.pdf
Anaesthesia UK, Inhalational Agent Tutorial, Updated 2014,
retrieved March 2015 from http://www.frca.co.uk/sectioncontents.
aspx?sectionid=81
Originally published [ Edmond I. Eger, II, MD, Characteristics of
Anesthetic Agents Used for Induction and Maintenance of General
Anesthesia, Am J Health Syst Pharm. 2004;61(20) ] [2004], American
Society of Health-System Pharmacists, Inc. All rights reserved. Reprinted
with permission (R1501). Retrieved March 2015 from www.medscape.
com/viewarticle/492432_3
Baker MT, Sevoflurane: are there differences in products? Anesth Analg,
2007;104:1447-1451. http://journals.lww.com/anesthesia-analgesia/

18.

19.
20.
21.

22.
23.

24.
25.

26.

Abstract/2007/06000/Sevoflurane__Are_There_Differences_in_
Products_.22.aspx
Kharasch ED - Sevoflurane: the challenges of safe formulation. APSF
Newsletter, 2007;48:55. http://www.apsf.org/newsletters/html/2007/
fall/03_sevoflurane.htm
ONeill B, Hafiz MA, DeBeer DAH - Corrosion of Penlon sevoflurane
vaporisers. Anaesthesia, 2007;62:421. http://onlinelibrary.wiley.com/
doi/10.1111/j.1365-2044.2007.05048.x/full
Kharasch ED, Subbarao GN, Stephens DA et al. - Influence of
sevoflurane formulation water content on degradation to hydrogen
fluoride in vaporizers. Anesthesiology, 2007;107:A1591. http://www.
asaabstracts.com/strands/asaabstracts/abstract.htm?year=2007&index=
15&absnum=1758
Stephens DA, Kharasch ED, Cromack KR et al. - Sevoflurane vaporizers
contain Lewis acid metal oxides that can potentially degrade
sevoflurane. Anesthesiology, 2007;107:A1597. http://www.asaabstracts.
com/strands/asaabstracts/abstract.htm?year=2007&index=15&absn
um=972
Cromack KR, Kharasch ED, Stephens DA et al. - Influence of formulation
water content on sevoflurane degradation in vitro by Lewis acids.
Anesthesiology, 2007;107:A1593. http://www.asaabstracts.com/strands/
asaabstracts/abstract.htm?year=2007&index=15&absnum=770
Grupa A, Ely J - Faulty sevoflurane vaporizer. Anesthesia, 2007; 62:412.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2007.05049.x/full
Baker MT, Sevoflurane-Lewis Acid Stability, Anesth Analg 2009; Vol
108;1725-1726
Barash Paul G., Cullen F. Bruce, Stoelting Robert K., Cahalan Michael,
Stock Christine Generic Sevoflurane Formulations. Clinical Anesthesia,
6th edition, (978-0-7817-8763-5), page 423, chapter 17
Piramal Critical Care Inc., Urgent Drug Recall Notification Letter , dated
April 3, 2014 , issued by Eric L. Wesoloski Director of Quality
McNeirney, John C., Chief Technical Officer Mindrad, Dr Terrel, Ross
Minrad PhD, Minrad. Complex Chemistry Causes Controversy Minrad
Provides Packaging Perspective, Anesthesia Patient Safety FoundationAPSF newsletter Winter 2007-2008, pages 85-86
Jean-Frangois Hardy, letter to the editor Vaporizer Overfilling, Canadian
Journal of Anaesthesia , January 1993, Volume 40, Issue 1, pp 1-3
FDA Piramal Critical Care Inc, Sevoflurane recall enforcement
report week of May 7, 2014, http://www.accessdata.fda.gov/scripts/
enforcement/enforce_rpt-Product-Tabs.cfm?action=select&recall_
number=D-1262-2014&w=05072014&lang=eng
Fluoride Action Network, Review of Form 483 from FDA News:
Sevoflurane: Use of Potable Water Gets Drugmaker a 483, http://
fluoridealert.org/news/sevoflurane-use-of-potable-water-getsdrugmaker-a-483/

DISCLOSURE AND FUNDING


The author declares no conflict of interest. The authors
work has been funded by an unrestricted grant from
AbbVie Inc., through a project proposal submitted to
and approved by the RTSO Research Committee.
AbbVie Inc. staff or employees were not involved in any
process related to this review.
The views expressed in this article do not necessarily
represent the views of The RTSO.

RTSO Airwaves - Spring 2015 Page 31

Student Corner - My Transition from SRT to RRT

Student Corner
My Transition
from SRT to RRT
The end of clinical quickly approaches by finishing
off major case presentations and preparations
for the national exam. I attended the Michener
Institute for Applied Health Sciences for Respiratory
Therapy in Toronto. Although the end was near for
formal education, the real learning occurs once
you enter the field on your own as a new graduate.
Towards completion, I experienced a roller coaster
of emotions: a feeling of excitement of completing
my education; a gratifying feeling to be financially
compensated; and an eagerness to apply my skills
to improve a persons quality of life; I also had
feelings of uncertainty in regards to job prospects,
anxiety of conquering the national board exam, the
stress of maintaining patient care and safety on my
own and fitting into the workplace.
The first thought that comes to a new graduates
mind is, will I be able to secure a job?. My
classmates and I were told from the start of clinical
that job prospects were gloomy and we would
likely attain casual positions, if there are any at all,
in Toronto. I strongly considered moving out west
but decided to try and exhaust options here first,
as Toronto is home. I was fortunate enough to
experience a number of interviews, and in the end
accepted two casual positions before graduation. I
was overwhelmed at first as to how to manage both
positions, but scheduling was easier than expected
since one of my jobs is in acute care (with a set
schedule as per availability) and the other job is in

Katherine Tran RRT


pulmonary function testing (shifts covered on an as
needed basis). I enjoy working in two different areas
of Respiratory Therapy. In the acute care setting, I
enjoy applying my knowledge and skills in active
patient care and management while working with
an interprofessional team. In pulmonary function
testing, I enjoy the one-to-one patient interaction,
which enables me to provide education and be
part of the patients journey, investigating the
cause of a chronic cough or helping to determine
if a patient may have asthma. I appreciate the
benefits of working in the acute and diagnostic
setting as this has enabled me to make the most
out of my education and continue to develop my
communication skills.
The Canadian Board for Respiratory Care (CBRC)
exam was another obstacle to overcome post-

Page 32

RTSO Airwaves - Spring 2015

Student Corner - My Transition from SRT to RRT

graduation. I was working full-time hours for


orientation while trying to prepare for the exam, so
finding time to study was challenging. Any day off
was dedicated to reviewing materials. As a stress
reliever, I took up exercising. I felt great benefits
with exercise as it took my mind off of anything
respiratory related and allowed me to focus on
my well being. I would recommend, as my clinical
coordinator had suggested, that clinical students
find ways to relieve stress -- whether it is exercise,
cooking, reading or other activities. If you are in
a time crunch to prepare for the exam, focus on
theory or skills you have not been exposed to
recently and stick to a study schedule. A good
night sleep prior to the test date will consolidate
materials, relieve anxiety and optimize your ability
to focus on the exam. The clinical year has prepared
you this far, now you just have to bring it all back
together and apply those skills.
So now that you are a graduate (GRT)/registered
(RRT) respiratory therapist, are you completely
independent? Yes and no. Trust that your education
and experiences have provided you with a level
of confidence to plan the course of your patients
care. If I have questions or need a second opinion,
I will not hesitate to ask. I was told that it takes 2-3
years post graduation as a Respiratory Therapist
to truly know what you are doing. I am fortunate
to be surrounded by supportive colleagues who
have been in my shoes and are willing to share their
experiences, tricks and tips; I also have close friends
and families who are there to lend an ear after a
tough day in the ICU. One event that I recently
experienced was a patients unexpected vasovagal
response while suctioning, which caused the
patient to become asystolic. It took me by surprise,
as this was not the first time I had suctioned
this patient. The nurse quickly called a code as I

maintained airway/breathing, and a colleague


continued suctioning as this patient was full of
secretions. Fortunately, the patient quickly had
return of spontaneous circulation (ROSC). Shortly
after, I was in a calm state of shock and although I
did not think much of it, my colleagues reassured
me that it was not my fault, as I was doing what
needed to be done. Later, I was surprised when
the ICU staff physician approached me to
reassure me of my actions as well. Reflecting on
this, it was through this experience I realized that
I am not alone, and I am lucky to be in a positive
work environment.
For some graduates like me, this is the first time
entering the real, working world. I wondered how
would I fit in the department and I wondered how
to further develop and grow professionally. What
has worked for me is to be my genuine self while
maintaining professionalism, of course! Be honest
and respectful of others and know your limitations.
Share little details of yourself and others will open
up to you. Even though I am a new graduate and
have been working for at least 6 months, its never
too early to find opportunities for professional
growth. I believe it is important to seek out every
learning opportunity to advance my career
and growth with the profession -- whether it is
attending workshops, conferences or volunteering.
My advice is to be courageous and assertive -- you
will be surprised where it will take you!
Tips for Clinical Students/New Graduates
Start your resume during your clinical year
Only include experiences relevant to the job
Seek out or notify your references to expect
calls or emails from potential employers.
Search for jobs daily and check internal hospital
websites at your clinical site

RTSO Airwaves - Spring 2015 Page 33

Student Corner

epoc Blood Analysis System


Reduces Costs, Improves Operational
Efficiencies, and Enhances Patient Care

The epoc System provides the flexibility to meet your STAT testing needs:

Blood gases, Electrolytes, Glu & Lactate


(Calculated values: cHC03-, cTC02, BE (ecf ), BE(b), cS02 and cHgb)
Room temperate storage
Simplified inventory management (all tests on one card)
Only 92ul sample required
35-seconds to result time
Blurtooth, Wireless connectivity, barcode capability
HL7 LIS interface

For pricing or to schedule a visit with a


respresentative simply email:
CANproductsupport@alere.com
Further information on Alere epoc
test may be found at:
http://www.alere.com/ww/en/product-details/
epoc-blood-analysis-system.html

Make treatment decisions faster with the

epoc Blood Analysis System

1.800.818.8335
2011 Alere. All rights reserved. The Allere Logo and Alere are trademarks of the Alere group of compaies.
epoc isa trademark of Epocal Inc. under license. PN: 1000376-01 12/11

Practice interviewing skills


with friends, professors or
student counsellors
Ask interviewers for
feedback if you were not
a successful candidate for
their job. (They will gladly
provide feedback)
When answering
interviewing questions,
provide examples of your
experiences from clinical
Once you have landed an
RT job and have worked
for a while, plan your welldeserved vacation!
Bio:
Katherine Tran is a recent
graduate from the Michener
Institute for Applied Health
Sciences for Respiratory
Therapy in 2014. She has taken
an active role at Michener
on Student Council and is a
strong advocate for Respiratory
Therapy. Katherine also holds
an Honours Bachelor of Science
degree from the University
of Toronto (St. George) in
Health and Disease major
and Physiology and Human
Geography minors in 2011.
She is currently working as
a Registered Respiratory
Therapist at the Toronto
Western Hospital and St.
Michaels Hospital Pulmonary
Function Lab.
RTSO Airwaves - Spring 2015

Management Corner
Dont let your ego get in the way of your desire to
learn. Successful people keep their minds open
to new things because they know that no matter
how high their level of mastery, there is always
more to discover. If youve become an expert
in one specific aspect of the RT role, seek out
other fields where you can transfer and apply
your expertise. When facing challenges, even
ones youve faced many times before, adopt a
learners approach; ask questions or find new
ways to solve the problem.

Take Responsibility For Your Growth


Responsibility for your professional development
lies squarely on your shoulders. No matter your
situation, use these tips to keep sharp.
Meet with coworkers each month. Talk about
the industry and where it is headed. This will
keep you tapped into the RT community.
Have one major learning experience each
quarter (every 3 months). If your work isnt
giving you the necessary challenges, seek out
other opportunities. Attend a conference, a
workshop or take a class.
Give yourself a performance review. Reflect on
your growth and performance, whether through
a formal process or not. Be honest with yourself
about your strengths and weaknesses and what
you should focus on in the coming year.

Lucy Bonanno
RRT, MA, MBA, CAE, CHE

The more that you read, the more things you


will know. The more that you learn, the more
places youll go.
~ Dr. Seuss

The journey of a thousand miles begins with one


step.
~Lao Tzu

RTSO Airwaves - Spring 2015 Page 35

Canadian Institute for


Health Information
(CIHI) Updates

Laura Eyre, Program Consultant, and Arlene


Thiessen, Senior Analyst, both from from CIHI,
co-presented updates on, CIHI Update on
the MIS Standards and Respiratory Services
revisions at InspirEvolution 2014.
Management Information Systems (MIS)
Standards are a set of national standards
that provide an integrated approach to
managing financial and statistical data related
to the operations of Canadian health service
organizations (www.cihi.ca). Data quality and
information quality are fundamental to CIHIs
mandate to inform public policy, support health
care management and build public awareness
about the factors that affect health.
CIHIs data quality program is recognized
nationally and internationally for its
comprehensiveness and high standards.
CIHIs goal is to continuously improve data
and information quality within CIHI and the
broader health sector. With that mandate,
CIHI has a strategy for data quality based on a
six-point plan designed to foster a data quality
culture, strengthen data quality infrastructure
and capacity, cultivate the data supply chain,
enhance external data quality collaboration,

initiate fast-track priority projects, and promote


communication and provide consultation.
Improving data and information quality is
a collaborative effort. CIHI works with data
suppliers and users to support each of these
activities. Therapists play an integral role in
helping to manage the quality of CIHI data as
measured through MIS Standards Respiratory
Services workload. The RTSO has been
collaborating with CIHI on Respiratory Services
revisions and the Respiratory Services Workload
Measurement System has been thoroughly
reviewed, including a review of the current
service activity procedures (2003). These 2003
standards emphasized tasks, whereas our Scope
of Practice has widened to a more holistic model
where client education, population health,
rehabilitation and community support are now
part of the norm for Respiratory Services. As a
result, work is ongoing, methodology for data
collection is under review, and the expected
completion date is set for June 2015.

redeveloping the MIS Standards for respiratory


services. Working Group members are
published on pages 5 & 6 in Redevelopment
of the MIS Standards: Respiratory Services,
http://www.cihi.ca/cihi-ext-portal/pdf/
internet/mis_rsrp_part3_improving_en. Part
2: The MIS Standards and Data Use available
on the CIHI website: http://www.cihi.ca/
cihi-ext-portal/pdf/internet/mis_rsrp_part2_
overview_en
If you would like to become involved in this
project, it is not too late to ask questions,
provide input or feedback. You may contact
Nancy Hunter, Ontario Ministry of Health and
Long-Term Care: Nancy.Hunter@ontario.ca.
You may also e-mail rsmis@cihi.ca or speak

with one of the CIHI Respiratory Services


Working Group members.
The aim is for revisions to be incorporated
into new MIS Standards for implementation
beginning April 1, 2016.
Updates on redevelopment are posted on the
CIHI website (www.cihi.ca) with the latest
posting Update on the Redevelopment of the
MIS Standards for Respiratory Services: Part 3
Improving Data Quality available at http://
www.cihi.ca/cihi-ext-portal/pdf/internet/
mis_rsrp_part3_improving_en and Part 4:
Implementing the Respiratory Service Revisions,
is due out this Spring. Stay tuned!

Currently there are a number of individuals on


either the Respiratory Services Working Group
or the Technical Working Group, and CIHI
values the input of Respiratory Therapists in

36

RTSO Airwaves - Spring 2015

RTSO Airwaves - Spring 2015 Page 37

More reasons to be a
member of the RTSO
1. Leadership - Province wide peer support
and networking opportunities
2. Community RT advocacy to ensure better
care for the patient in the community

RTSO Membership works for

TWO GREAT RTSO EDUCATIONAL EVENTS


COMING THIS FALL
Inspire 2015 RTSO Education Forum

RTSO Education Conference

November 13, 2015 - 7:30am - 4:00pm

October 29, 2015 - 7:30am - 4:00pm

Mississauga Grand Banquet Hall

Hellenic Meeting and Reception Centre

35 Brunel Road, Mississauga

1315 Prince of Wales Dr, Ottawa

Hotel accomodations available

Hotel accomodations available

EXHIBITOR PACKAGES NOW AVAILABLE


PARTICIPANT REGISTRATION COMING SOON
VISIT WWW.RTSO.CA OR CONTACT THE RTSO OFFICE AT

647-729-7217 / 1-855-297-3089

YOU

Key Initiatives Include:


1. Advocacy - Our strength and integrity
as Respiratory Therapists lies in our
collective voice at the provincial
and national levels. Health care is
determined at the provincial level in
Canada and the RTSO is best positioned
to provide the provincial influence.
2. PL&I - Our comprehensive insurance plan
covers you beyond your basic insurance
needs as a Respiratory Therapists.
Combined with your membership
package it is also economical.
3. ORCS membership - all of the benefits
that are included with membership in
the Ontario Lung Association are now
included. (visit www.lung.on.ca or call
1-888-344-(LUNG) for full details

3. Research Committee as a resource to


enhance your career as a Respiratory
Therapist
4. Student Committee as a resource for
student career development
5. Career enhancement programs such
as the annual Educational Forum and
seminiars
6. Special Stethoscope discount available to
members
7. Timely critical issues updates. Up to the
minutes details on what you need to
know.
8. Your liaison with the CRTO, our provincial
regulatory body
9. RTSO Airwaves gives you quarterly
news of the proud accomplishments of
Respiratory Therapists. A great read!
Want more? Check out the rtso web site.
Membership applications available on line

w w w. r t s o . c a
160-2 County Court Blvd, Suite 440
Brampton, ON L6W 4V1



Got a question for aRTee?
Contact the RTSO at
office@rtso.ca and your
question may be featured
in an upcoming edition of
RTSO Airwaves.

Ask aRTee
Dear aRTee,
My hospital will be going through Accreditation
in June and I keep hearing talk of ROPs. I dont
know what that means and Im too embarrassed to
ask. Can you help?
Thanks,
Clueless Cal

Dear Cal,
Accreditation is a continual process of assessing
your organization against standards to identify
what you do well, where you can make
improvements, and how make those improvements
happen.
According to Accreditation Canada1, accredited
employers have demonstrated commitment to:

Improving quality and safety

Reducing risk

Medication Reconciliation, Workplace Violence


Prevention, and Hand Hygiene Compliance are
examples of Required Organizational Practices.2
If youd like more information, there is a
downloadable handbook available to you that
clearly outlines the ROPs for either the 2015 or
2016 Accreditation cycle -- check it out!

2. http://www.accreditation.ca/sites/default/
files/rop-handbook-2015-en.pdf
3. http://www.accreditation.ca/sites/default/
files/rop-handbook-2016-en.pdf

Winners of the RTSO Early Membership Registration for 2015-2016 draw


Increasing efficiency and decreasing costs

Implementing best practices
An ROP is a Required Organizational Practice
there are many ROPs that are evidence-based
practices, proven to reduce risk and improve
quality and safety when implemented1. ROPs are
developed using a similar process to that of the
standards - utilizing consultation, research, and
evaluation to build.1
In Canada, ROPs are an important part of the
accreditation program, addressing vital safety
issues within six safety goal areas, and there is
something called primer standards, with these
divided into nine sections1:
Leadership

Client Safety

Integrated Quality Improvement

Safe and Healthy Worklife

Information Management

Physical Environment and Equipment

Medication Management

Page 36

References:
1. Accreditation Canada http://www.
accreditation.ca/accreditation-menu

Infection Prevention and Control


Safe and Appropriate Service Delivery

RTSO Airwaves - Spring 2015

Kyle Davies, RTSO President made the


draw for the 5 lucky winners of the
RTSO early membership registration for
2015-2016.
The winners are:
Dale Mackey
Catalina Restrepo
Alan Shelley
Virginia Teasdale
Paul Williams

The winners each received a $100 RBC Visa Gift Card.


Congratulations!
RTSO Airwaves - Spring 2015 Page 37

160-2 County Court Blvd, Suite 440


Brampton, ON L6W 4V1
Tel: 647-729-2717/Fax: 647-729-2715
Toll Free: 1-855-297-3089
E-Mail: office@rtso.ca

160-2 County Court Blvd, Suite 440


Brampton, ON L6W 4V1
Tel: 647-729-2717/Fax: 647-729-2715
Toll Free: 1-855-297-3089
E-Mail: office@rtso.ca

www.rtso.ca

www.rtso.ca

MeMbership ApplicAtion April 1, 2015 - March 31, 2016

MeMbership ApplicAtion April 1, 2015 - March 31, 2016

First Name: ________________________ Last Name: _____________________________CRTO Number: ___________________

pAyMent options
Mailing Address: __________________________________________City ______________________Postal Code______________

Personal Telephone: _______________________________ Email: ____________________________________________________

CHOOSE YOUR MEMBERSHIP OPTION


Membership Fee

Indicate if you prefer correspondence via email

or print

Employer: ________________________________________
(School, if student)

(RTSO correspondence is primarily conducted via email)


Position:______________________________________________

Bus Telephone: ______________________________ ext.: _______________


Advocacy

Research

RTSO Airwaves

Fax: ___________________________________

Student Affairs

Leadership

Community RT

HST

Total Membership

Total Remitted or
Authorized

prActicing MeMber
Option 1

$185.00

$24.05

$209.05

Option 2

$140.00

$18.20

$158.20

$170.00

$22.10

$192.10

$30.00

$3.90

$33.90

$200.00

$26.00

$226.00

AssociAte MeMber
student MeMber
corporAte

MeMbership OptiOn DescriptiOns

totAl

prActicing MeMber
Option 1
PL&I included

Professional Liability & Indemnity Insurance and Ontario Respiratory Care Society $209.05 (HST $24.05 incl)
(ORCS) Membership & benefits*** included

Option 2
NO PL&I included

Ontario Respiratory Care Society (ORCS) Membership & benefits*** included

$158.20 (HST $18.20 incl)

AssociAte MeMber

Ontario Respiratory Care Society (ORCS) Membership & benefits*** included


No PL&I

$192.10 (HST $22.10 incl)

student MeMber

1 yr from date of RTSO membership registration. No ORCS membership or PL&I


Indicate Year of Graduation ( 20___)

$33.90 (HST $3.90 incl)

Cheque (payable to The Respiratory Therapy Society of Ontario) and remitted to the RTSO office noted above
PayPal - please complete the on line form available on www.rtso.ca
Note: A PayPal account is not necessary. Visa/MasterCard/American Express/Discover/Interac are all accepted means of payment.

Visa or MasterCard (no American Express) are also available without PayPal - please complete the following:

Note: First year Graduates are free, however the graduate MUST complete and
register as a Practicing Member on the appropriate membership form. To qualify,
the graduate MUST have been an RTSO student member for a minimum of 3 years
prior to graduation and MUST provide his/her CRTO Registration Number within
one year of graduation. Professional Liability & Indemnity Insurance coverage is
free for the first year if the grad is completing their licensing requirements while
he/she is under supervision of an RTSO member who is licensed.

corporAte

CHOOSE YOUR PAYMENT OPTION

Member Name: ________________________________________________


Cardholder Name: ______________________________________________
$226.00 (HST $26.00 incl)

HST Registration # 107889339


An Associate Member is an individual not holding a certificate of registry from the CRTO.
*In choosing to apply for the Professional Liability & Indemnity Insurance**, the undersigned respiratory therapist declares that he or she has never been the
recipient of a claim which could be covered under the present policy; or is not aware of any circumstances which could lead to a claim under the present
policy.
**Professional Liability & Indemnity Insurance coverage: $2M/incident / $4M aggregate; Nil Deductible
Disciplinary Defense: $175,000/claim / $175,000 Annual Aggregate
Criminal Defense Reimbursement: $200,000/incident / $200,000 Annual Aggregate;
Sexual Abuse Counselling & Rehabilitation: $10,000/insured / $250,000 Annual Aggregate
Legal Representation Expenses: Subpoenaed as witness $1,500 each claim
Complaint $5,000 / Max annual aggregate for both $50,000

VISA/MasterCard #: _____________________________________________ Expiry Date: ______________________


Cardholder Signature: ___________________________________________

RTSO Privacy Notice


The process of collection and using information about individuals is now more complicated as a result of legislation, the Personal Information Protection and Electronic Documents
Act (PIPEDA). PIPEDA applies to personal information. It is information about an identifiable individual, but does not include the name, title, and business address or business phone
number of an employee of an organization. It does not apply to information about corporations, PIPEDA applies only to individuals. Any personal information collected by RTSO is
used solely for the purposes of providing membership services and will not be used for any other purpose without your consent.

***Please visit www.on.lung.ca/orcs or call 1-888-344-(LUNG), ext 256 for complete details of ORCS membership

RTSO Airwaves - Spring 2015 Page 39

Home Oxygen Programs


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Standard Clinical Program

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> Clinical assessment


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> 24/7 on call

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> Home Safety Assessment


> Innovative education methods

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and safety

> Current and potential


activity levels

> National and International


travel needs

> Walking Diary and


ambulation goals

> Cutting edge products


(tele-monitoring trial)