RTSO Airwaves Spring 2015

RTSO AirwavesSpring Issue 2015

Featured in this issue:

Respiratory Therapists Without Borders

(RTWB)An Update

The Procurement of Anaesthesia Volatile Agents:

an Evidence-Based Review

Leadership ReportCommunity RT

ResearchManagement Corner

Student CornerCIHI Update

Ask aRTee

Caroline Janowski - RTWB 2014Read the full article - page 14Photo courtesy of RTWB

Presidents Message

Kyle Davies RRT BSc

160-2 County Court Blvd, Suite 440Brampton, ON L6W 4V1Tel: 647-729-2717/Fax: 647-729-2715Toll Free: 1-855-297-3089E-Mail: [email protected] www.rtso.ca

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 1.855.991.8191

Support for your COPD patients

RxTelehomecare.ca More than 37% decrease in ED visits More than 44% decrease in hospital admissions High patient satisfactionRemote monitoring in your patients own home

Monitoring and health coaching by RNs and RTs

Telehomecare is a program of the Ontario Telemedicine Network, a non-profit organization supported by the Ontario Ministry of Health and Long-Term Care and Canada Health Infoway. RTSO Airwaves - Spring 2015 Page 1

Editorialencourage 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 [email protected]

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 [email protected]

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

Kyle

RTSO Airwaves - Spring 2015 Page 3Page 2 RTSO Airwaves - Spring 2015

Shawna MacDonald RRTRTSO 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

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

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.

Namaste,

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, RRTLayout/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.

References:

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

LeadershipRTSO Committee Reports

Kyle Davies RRT BScThe 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

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.

Now on LinkedIn, Facebook and Twitter

Visit us for the lastest newsShare the conversation


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 Committee ReportsCommunity Respiratory Therapy

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)

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 ([email protected])

or Sara Han ([email protected]) to learn more.

Photos courtesy of Ginny Myles.

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

Below: From Right to Left - Kyle Davies, Sue Jones, Yvonne Perusse

Committee Reports - Community Respiratory Therapy


Research

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 2014by 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 multi-

centered 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

Enrich and augment opportunities for

respiratory research and capacity building

Train and mentor researchers with trans-

disciplinary 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.

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 PlatformDr. 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 PlatformDr. Christopher Carlsten (University of British

Columbia, Vancouver BC)

Goals: To integrate the COPD cohorts into

APELs (Air Pollution Exposure Laboratory) well-

developed 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 PlatformDr. 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 non-

smokers 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 PlatformDr. 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.

The Canadian Respiratory Research Network: Interdisciplinary Research in Canada

Nancy Garvey RRT, MAppSc

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


Pharmaco Epidemiology PlatformDr. 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 PlatformDr. 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 PlatformDr. 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 PlatformDr. 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 PlatformDr. 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 PlatformDr. 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.

The CRRN Training ProgramThe 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.

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 2: 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.

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

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


Research - The Canadian Respiratory Research Network: Interdisciplinary Research in CanadaResearch - 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 ENGAGEMENTThe 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 real-

time 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

Moving forward, if the breathe app is demonstrated

to be effective in helping symptom control and

reduce risk of disease progression, we would

like to further implement and promote the

uptake of the app and also expand the app to

include the COPD population. Partnering with

CRRN platforms to engage patients in disease

self-management will facilitate broad scale

implementation and knowledge translation.

KNOWLEDGE TRANSLATION

CRRN has adopted the CIHR Knowledge-to-

Action 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.

EXPECTED END-RESULTS AND IMPACT OF THE CRRNIn 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

program with graduation of new investigators,

postdoctoral fellows and graduate students. CRRN

will disseminate results from our collective efforts

to the greater community of patients, providers,

and policy-makers using integrated knowledge

translation vehicles. These participants will be

further studied using advanced airway physiology,

airway imaging, and biomarkers of airway

inflammation to assess pathophysiology and

functional impairment. Potential mechanisms of

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

One Breath at a time: respiratory update 2015Windsor, ONWednesday, May 6, 20155:45 p.m. - 8:30 p.m.Serbian Community Centre6770 Tecumseh Road East, Windsor

Spring InspirationsLondon, ONTuesday, June 9, 20158:00 a.m. - 4:00 p.m.Best Western Lamplighter Inn591 Wellington Road South, London

A Breath in Every Direction: Respiratory Update 2015Ottawa, ONThursday, June 11, 20158:00 a.m. - 4:00 p.m.Algonquin CollegeBuilding T, Room T-102AB1385 Woodroffe Avenue

For more information or to register, please go to www.on.lung.ca/orcs


Dear RTSO Membership,

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

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 UpdateAs 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.

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 [email protected]

2. Healthcare Education Partnership (HEP) UpdateFor further inquiries on becoming a healthcare education partner, please contact [email protected]

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

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.

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.

3. CommunicationsWe 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

Respiratory Therapists Without Borders

(RTWB)Nepal

Litein Hospital Africa


RTWB - An Update

website! If you have any suggestions or would like to get involved please feel free to email Arpita at [email protected]

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

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 [email protected].

Look forward to creating a culture of caring with you,Respiratory Therapists Without BordersRegistered Canadian Charity (# 833885437RR0001)

[email protected] || www.rtwb.ca 1844.4RT.STAT

Peace,Eric ChengCo-Founder & Culture CreatorRespiratory Therapists Without BordersRegistered Canadian Charity (3 833885437RR0001)[email protected]; www.rtwb.ca 1.778.239.9335

All photos courtesy of RTWB

Left: National NSCCM Conference 2014

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Page 16 RTSO Airwaves - Spring 2015

RTWB - An Update

THE PROCUREMENT OF ANAESTHESIA VOLATILE AGENTS: AN EVIDENCE-BASED REVIEW

IntroductionPatient 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.

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 Therapist-Anaesthesia Assistants and Anaesthesiologists prior to publication.

Procurement strategy for anaesthesia volatile agents in OntarioVolatile 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.

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


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

MethodologyIn 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 well-recognized 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

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)


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

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



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

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 PackagingThere 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



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.

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.

Table 1: Human tissue and Blood Gas Partition Coefficients at 37C (12)

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.

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

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

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

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.

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



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 agent-specific 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

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.

References: 1. 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

2. 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

3. Bovin JF (1997). Risk of spontaneous abortion in women occupationally exposed to anesthetic gases: a meta-analysis. Occup Environ Med 54:541-548

4. 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)

5. 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

6. Standards, Accreditation Canada. Managing Medications. http://www.accreditation.ca/programmmes-d-agrements/qmentum/les-normes

7. Michael P. Dosch CRNA PhD, The Anesthetic Gas Machine (updated July 2012), retrieved Jan, 2015 from http://www.udmercy.edu/crna/agm/05.htm

8. Ronald D. Miller, Lars I. Eriksson, Lee A Fleisher, Jeanine P. Wiener-Kronish, William L. Young, Millers Anesthesia Seventh Edition, pages 687-689, published by Churchill Livingston 2010

9. ORNAC. Recommended Standards, Guidelines, and Position Statements for Perioperative Registered Nurse Practice. Revised August 2003

10. 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

11. Anaesthesia UK, Inhalational Agent Tutorial, Updated 2014, retrieved March 2015 from http://www.frca.co.uk/sectioncontents.aspx?sectionid=81

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). Retrieved March 2015 from www.medscape.com/viewarticle/492432_3

13. Baker MT, Sevoflurane: are there differences in products? Anesth Analg, 2007;104:1447-1451. http://journals.lww.com/anesthesia-analgesia/

Abstract/2007/06000/Sevoflurane__Are_There_Differences_in_Products_.22.aspx

14. Kharasch ED - Sevoflurane: the challenges of safe formulation. APSF Newsletter, 2007;48:55. http://www.apsf.org/newsletters/html/2007/fall/03_sevoflurane.htm

15. 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

16. 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

17. 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&absnum=972

18. 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

19. 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

20. Baker MT, Sevoflurane-Lewis Acid Stability, Anesth Analg 2009; Vol 108;1725-1726

21. 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

22. Piramal Critical Care Inc., Urgent Drug Recall Notification Letter , dated April 3, 2014 , issued by Eric L. Wesoloski Director of Quality

23. McNeirney, John C., Chief Technical Officer Mindrad, Dr Terrel, Ross Minrad PhD, Minrad. Complex Chemistry Causes Controversy Minrad Provides Packaging Perspective, Anesthesia Patient Safety Foundation- APSF newsletter Winter 2007-2008, pages 85-86

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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.

Student Corner

Katherine Tran 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

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-

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

My Transition from SRT to RRT


Student Corner - My Transition from SRT to RRT Student Corner - My Transition from SRT to RRT

Lucy BonannoRRT, MA, MBA, CAE, CHE

Management CornerDont 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.

The

RTSO Airwaves Spring 2015

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