Research Location: Vancouver General Hospital

TEC4Home: Telehealth for emergency-community continuity of care connectivity via home monitoring

Patients with long term medical conditions like heart failure or chronic lung diseases typically get admitted to and discharged from hospitals frequently because their conditions fluctuate. For example, one out of four patients older than 65 with heart failure often needs to return to hospital within one month of a previous emergency room or hospital stay. Today, using electronic monitors, patients can measure their own blood pressure, weight, and blood oxygen from home, and send their measurements to doctors or nurses so they can supervise the patient’s state of health. We are testing this home health monitoring approach to see if it can help patients with heart failure or chronic lung diseases stay healthy and safe at home.

In our research program called TEC4Home, we hope to show that home monitoring: 1) helps patients to manage their illnesses better themselves because they know their own bodies best, and 2) allows nurses and doctors to follow patients closely without needing to visit them. We expect to show that these patients will stay well and not need to revisit emergency departments, thereby helping hospitals to save money or save the beds for sicker patients.

We will first invite 90 patients with heart failure from Vancouver General and St. Paul’s Hospitals to test the home monitoring approach after they go home. Findings will allow us to make improvements before we expand to enroll 900 patients in 30 hospitals in BC in a formal clinical study.

Provided TEC4Home is found to help patients and decrease hospital costs, we will expand this service to be offered to other patients with heart failure across BC. We will invite companies that make monitoring equipment to develop newer and better versions, and use our experimental approach to test these devices to ensure they are safe and useful. We will also test TEC4Home with patients with chronic lung diseases to expand TEC4Home to serve patients with more than one type of long term disease.

We will work closely with doctors, nurses, patients and families, hospital managers, government leaders, technology companies, and health researchers. Patients will not only test the approach, but will also be involved in planning and carrying out the research. We will share findings with governments and health organizations so that home health monitoring, if proven effective, will become a routine part of treating patients. We will present at medical conferences and publish to share learnings beyond BC.

End of award update: June 2021

Most exciting outputs:
The home health monitoring (HHM) research is now being applied in practice, within the fabric of the health system. What we have learned is being applied and has been used in policy making. Methods and an evaluation framework have informed not only this project, but the evidence used in the real world.

While results from the full randomized controlled trial are forthcoming, the findings from our feasibility study showed signals of overall positive impact. This included reduction of emergency department revisits, hospital readmissions, and hospital length of stay. Results also showed an improvement in quality of life and self-efficacy. Further, feedback from patient participants indicate the HHM service was well received and helped participants feel safer and more supported at home after discharge from the hospital.

The TEC4Home Heart Failure study also resulted in the expansion of the concept to new conditions (like hypertension) and new technologies (such as an in-home medication dispenser). These new projects will continue to collect and build a body of evidence to best inform how digital health can help support the transition of care from hospital to home for a variety of patient populations in BC.

Impact so far
The findings from this project have been used to inform the ongoing implementation of home health monitoring in BC. It is our goal to continue to add to this evidence and see the application of these findings in the health system.

Potential future influence
At a provincial level, as noted above, the PI, K. Ho, is a member of the Digital Health Committee in BC. This involvement allows for project findings to be applied in alignment with existing policies and to inform emerging policies.

Further, the PI, K. Ho, is also a member of multiple national committees, such as the Canadian Virtual Care Task Force (focused on digital health implementation and education); the National Research Council (focused on medical device research with influence on national digital health research in practice); and the Health Canada scientific advisory committee (focused on the regulation and support of industry in digital health). All of these memberships provide opportunities for health policy influence.

Next steps
Over the course of the next year (to Mar 2022), we will be completing the final analysis of our TEC4Home Heart Failure randomized controlled trial. The results will be shared back to our various project committees and partners, including all of the patient participants. We will also seek more dissemination opportunities, such as publication in a high impact journal and presentation at conference(s).

In addition, as previously mentioned, with recently acquired funding, we are applying the TEC4Home concept to new conditions (hypertension) and new areas of impact (medication adherence). We are also incorporating the use of data analytics to deepen our understanding and the application of home health monitoring. This expansion of TEC4Home will continue to develop the evidence base of the use of technology to support patients safely at home, as they transition from acute to community care.

Useful Links
Digital Emergency Medicine (DigEM) website: TEC4Home Heart Failure | Digital Emergency Medicine (ubc.ca)
https://digem.med.ubc.ca/projects/tec4home-telehealth-for-emergency-community-continuity-of-care-connectivity-via-home-telemonitoring/

Feasibility Study publication: Testing the Feasibility of Sensor-Based Home Health Monitoring (TEC4Home) to Support the Convalescence of Patients With Heart Failure: Pre-Post Study – PubMed (nih.gov) https://pubmed.ncbi.nlm.nih.gov/34081015/

Trial Protocol publication: Supporting Heart Failure Patient Transitions From Acute to Community Care With Home Telemonitoring Technology: A Protocol for a Provincial Randomized Controlled Trial (TEC4Home) – PubMed (nih.gov)
https://pubmed.ncbi.nlm.nih.gov/27977002/

VCH news article about launch of trial: TEC4Home moves forward to clinical trials – Vancouver Coastal Health (vch.ca)
http://www.vch.ca/about-us/news/news-releases/tec4home-moves-forward-to-clinical-trials

Blog post by HeartLife: TEC4Home: Improving self-care management for heart failure patients – HeartLife Foundation
https://heartlife.ca/2019-3-1-tec4home-improving-self-care-management-for-heart-failure-patients/

The Impact of a Resident Work Schedule Change on Patient Safety

After graduation from medical school, physician education continues in a residency program in the individual's chosen area of specialty (e.g., Surgery, Internal Medicine). Residency programs have grueling schedules with frequent on-call shifts. These shifts are at least 24 hours in length, starting from the morning of one day and extending to the next day. In teaching hospitals, residents often provide first line care and make important decisions independent of direct supervision. Their clinical performance is thus an important determinant of patient safety. Some have argued that shift length should be reduced to a more reasonable amount (e.g. <16 continuous hours) to reduce fatigue and medical errors, and to improve safety.

Continue reading “The Impact of a Resident Work Schedule Change on Patient Safety”

Optimization of Trauma systems

Every year approximately 400,000 British Columbians suffer a traumatic injury — the leading cause of mortality and morbidity in Canada. The development of trauma systems to improve the access of injured patients to timely, and often life saving care is a health care priority. Unfortunately, access to timely and appropriate trauma care is not universal in BC. For example, injured patients in rural communities typically face economic, social and geographical barriers to care. In contrast, injured patients in urban communities are typically in close proximity to several hospitals; however, the trauma capabilities within in each hospital are highly variable, so choice of hospital may impact survival. This team of trauma surgeons, trauma care providers, geographers and epidemiologists is building a comprehensive dataset to investigate the performance of, and identify gaps within, the delivery of trauma care in rural and urban communities. The team’s goals will be to create evidence-based solutions where population vulnerabilities exist, and increase the reach and capability of the BC’s trauma system to address disparities in trauma outcomes across the province.

Examining segmental sensory function and recovery in individuals with spinal cord injury using dermatomal somatosensory evoked potentials

More than 30,000 Canadians live with spinal cord injury (SCI). SCI often leads to devastating neurological deficits that markedly reduce quality of life and life expectancy. During the first year of SCI, individuals typically recover some sensory function. Sensory testing, an important component of early diagnosis and prognosis, is currently done with light touch and pin prick sensation tests. Though this method is valuable for quickly assessing sensory function, it has limitations: it is difficult to obtain reliable results from uncooperative or unconscious individuals, it does not provide a quantifiable measure of sensation, and does not identify minor changes in sensory function. In undamaged sensory pathways, electrical impulses are rapidly conducted along mixed nerves to the spinal cord, where they ascend in sensory pathways to the brain. Following SCI, the spinal cord is typically compressed and damaged but not completely severed, meaning an electrical signal can still be recorded from the brain. However, this signal is expected to be delayed and to undergo distinct changes in the path it follows to the brain. John Kramer is examining spinal cord conductivity during recovery, applying methods currently used in clinical neurology, but new to SCI practice. He is assessing conductivity at each level of the spine by stimulating specific areas of the skin’s surface with electrical current, and recording the activity with scalp electrodes. To describe the contribution of sensory function at each level to sensory recovery, he will conduct these tests multiple times over the first year of SCI. Kramer’s investigation will provide important information concerning sensory recovery following SCI. The results from this study will have implications for delivery of care for individuals with SCI, and will prove beneficial for determining the efficacy for future SCI interventional therapies

Development of a screening strategy for community-based adverse drug related events in the emergency department

Adverse Drug Related Events (ADREs) are the most common type of preventable non-surgical adverse event related to medical care, and represent a leading cause of death. Each year, in BC alone, Emergency Departments treat an estimated 130,000 patients for ADREs, most of which are caused by medications prescribed in community settings. Unfortunately, community-based programs aimed at detecting and reducing drug-related problems have not led to a significant decline in morbidity, mortality or health services utilization. Emergency Department practitioners are well situated to play a pivotal role in the timely recognition and treatment of community-based ADREs. Unfortunately, Emergency Physicians currently detect only 50% of ADREs, missing opportunities to intervene.

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Bioinformatics of sequence indels: Novel applications for protein network analysis, drug target identification and drug development

Infectious diseases continue to be a huge threat worldwide. The effectiveness of current antibiotics is declining as many life-threatening bacteria have developed resistance to existing drugs, giving rise to the need for a new generation of antibiotics. An important factor responsible for emerging bacterial resistance is that conventional antibiotic drugs are designed to disable proteins on bacteria that allow it to infect host cells. These particular proteins mutate readily, which enhances their potential to develop resistance mechanisms against antibiotic treatment. An alternative strategy in antibiotic development would be to target “conserved” proteins – fundamental proteins that are resistant to mutations, because they perform essential functions that keep the bacteria alive. Michael Hsing’s research is focused on developing antibiotics that selectively target conserved and essential proteins in pathogens. To do this, he is investigating the important biological phenomenon of protein insertions and deletions (referred to as indels) and combining this approach with the latest computational tools to develop novel antibiotics that are more rapid and effective than the conventional approach. His goal is the development of an effective and economical method of developing antibiotic drugs to treat existing and emerging pathogens.

Detecting, Treating and Preventing Drug-Related Morbidity

In Canada, 7.5 per cent of hospital admissions are complicated by an adverse event related to medical care that leads to death, disability, or a prolonged hospital stay. Adverse drug related events (ADREs) represent the most common cause of preventable non-surgical adverse events, with up to 130,000 patients in British Columbia (BC) presenting to Emergency Departments with a symptomatic ADRE. However, there are currently no efficient screening strategies for ADREs. This team is working to develop and evaluate a clinically effective, resource-efficient screening strategy. Once the strategy has been proven effective in an Emergency Department setting, the team aims to adapt it for use in community-based practice, and determine its cost effectiveness in comparison to the current standard of care.

Independence of identity and expression? A look at facial processing in both healthy and patient populations

Recognizing facial expressions and identities plays a crucial role in daily life. People who have experienced damage to identity recognition regions of the brain due to stroke, trauma or other causes are unable to recognize the identity of faces, often including their own. People with damage to regions involved in expression recognition have difficulty interpreting expressions, which leads to social mistakes. Problems in expression recognition may have a role in autism and other social developmental disorders. Studies have suggested that specific brain regions are primarily involved in either facial identity recognition or facial expression recognition. However, recent studies, including research Christopher Fox has contributed to, suggest the two are not restricted to independent regions. Fox is designing a series of psychophysical tests to determine the extent of the overlap and using functional magnetic resonance imaging to measure brain activity in both healthy individuals and those who have experienced brain damage. Fox aims to determine whether an area of the brain previously thought of solely as an expression recognition region is also able to process facial identity. The research could lead to new therapies for people with facial recognition disorders. Fox was funded as a 2005 trainee award recipient for research on the role of the temporal lobes in vision and the process of visual perception.

The biological role of bone marrow-derived keratinocyte precursor cells in wound healing

Skin, which is the most extensive organ in the human body, performs multiple vital functions. Wounds to this organ, whether chronic or acute, are a serious threat because they leave the body open to infection. That’s why burns are a major cause of infection-associated deaths and why early replacement of burned tissues is so critically important. There is an urgent need to engineer skin substitutes for patients with extensive burns who do not have enough skin available for harvesting as grafts to close wounds. However, relatively little is known about how to establish a large-scale production of skin substitutes and how to control the healing process when such material is used. Bone marrow-derived stem cells may be a potential source for the preparation of skin substitutes due to their capacity to be reprogrammed to produce a variety of cell types. Abelardo Medina is studying whether bone marrow-derived stem cells can be used in this fashion both to close wounds and to improve wound healing. Findings from his research may also lead to a better understanding of the healing process and the treatment of chronic non-healing ulcers that develop in elderly people, diabetic and immuno-compromised patients. It also may contribute to a better understanding of the processes associated with over-healing wounds such as those that result in thick burn scars.

PTEN Regulates Alternative Splicing

Prostate cancer is the most common non-skin cancer among Canadian men and the second leading cause of cancer death. Prostate cancer starts in the prostate gland, part of the male reproductive system. Frequently, men with early prostate cancer have no warning symptoms. PTEN is a tumour suppressor gene that has been linked to prostate cancer. PTEN helps promote apoptosis (cell death), which helps regulate the uncontrolled cell growth that occurs in cancer; unfortunately, PTEN is often mutated in advanced stages of prostate cancer. Alternative splicing is an integral part of normal cell function, and is important for generating protein diversity and controlling protein function. Tien Yin Yau’s study investigates whether PTEN plays a role in regulating alternative splicing. Yau is studying whether changes in normal mRNA splicing increase susceptibility to prostate cancer by affecting genes implicated in tumor progression. The findings of Yau’s study will increase our knowledge of the molecular mechanisms that regulate alternative splicing. Understanding what changes occur and their effects may result in the development of more effective cancer treatments.