Division of Neurology



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Physician Resources

Division Highlights

The FTE complement for the Division of Neurology is 11.9. Eleven neurologists are hospital-based; 5 are communitybased but provide varying degrees of in-hospital patient care and teaching; and 6 neurologists are exclusively community-based.

Dr. Sultan Darvesh received the very prestigious DMRF Irene MacDonald Sobey Endowed Chair in Curative Approaches to Alzheimer’s Disease in May 2014. Dr. Laine Green presented an oral and poster presentation at the 2013 American Headache Society Scottsdale Headache Symposium which was in association with his American Headache Society Frontiers in Headache Research Scholarship. Dr. Gordon Gubitz was selected to receive a Heart and Stroke Outstanding Volunteer Award, recognizing him as a dedicated volunteer in Nova Scotia. Dr. Colin Josephson, a clinical and research fellow in epilepsy, was awarded the Susan S. Spencer Clinical Research Training Fellowship for his work in developing a clinical decision tool that is aimed at improving quality of patient care and helping ensure cost-effective use of healthcare resources. The research grant is funded by the American Brain Foundation, The American Epilepsy Society and the Epilepsy Foundation. The award recognizes the importance of epilepsy clinical research with the goal of providing better treatment, prevention or cure of the disease. Dr. Colin Josephson was also the recipient of the Canadian Institute of Health Research grant. This is a very prestigious award. His application ranked 3rd out of 48. Only the top 6 were funded. Drs. Sandy MacDougall and Virender Bhan and the Dalhousie MS Research Unit team received a special thank you and donation from a grateful patient who has received care at the MS Clinic. The Angel in Action donation is in support of the Dalhousie MS Research fund to honor the exceptional care, compassion and attention received at the MS Clinic. Dr. Jock Murray received Canada’s highest honor for physicians. Dr. Murray was officially inducted into the Canadian Medical Hall of Fame in April. He was among

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six visionary leaders to be so honored in 2014. Dr. Jock Murray also received an Honorary Degree, Doctor of Laws (honoris causa) at the Dalhousie University Medical School Convocation, May 2013. Dr. Michael Thorne received the Dr. Graham Gwyn Memorial Prize in Neurology.

The District Stroke Program, under the medical leadership of Drs. Stephen Phillips, Gordon Gubitz, and Anita Mountain (Division of Physical Medicine and Rehabilitation) continues to evolve within the Provincial Stroke System, which is directed by Cardiovascular Health Nova Scotia. The Acute Stroke Unit on 8.1 in the Halifax Infirmary provided care for 460 patients in 2013. Although the majority of these individuals were residents of Capital Health, the unit also treats people from other District Health Authorities, the Maritime Provinces, and beyond. The Acute Stroke Unit and Team also serve as a provincial resource for the training of personnel from other District Stroke Programs. Over 1,300 patients attended the rapid access Neurovascular Clinic, which is held at the Cobequid Centre on Mondays and at the Halifax Infirmary Tuesday through Friday. The Vascular Neurology group continues to participate in weekly Neurovascular Case Conferences, in conjunction with Neurosurgery and Neuroradiology, to develop interdisciplinary management plans for patients with complex neurovascular problems. In addition, the Vascular Neurology group collaborates with the Connective Tissue Disease program, which is led by Dr. Gabrielle Horne in the Division of Cardiology. The epilepsy program under leadership of Drs. Mark Sadler and Bernd Pohlmann-Eden further evolved. The Halifax First Seizure Clinic (HFSC) saw more than 650 patients by the end of the year. The best care practice of the HFSC, with a systematic treatment and diagnostic algorithm, was internationally recognized as a model approach. Dr. Bernd Pohlmann-Eden was invited to present the current experience as invited speaker at the American Epilepsy Society Meeting in Washington in 2013.



Dr. Ian Grant and Dr. Tim Benstead continue to develop the interdisciplinary ALS Clinic at the Nova Scotia Rehabilitation Centre in conjunction with members of the Division of Physical Medicine and Rehabilitation. This year staff shortage including the retirement of a senior technologist placed great stress on the remaining staff in the EEG/EMG lab, and reduced our ability to provide service. Two students were hired in an attempt to alleviate the problem. We expect reduced testing volume availability for at least another 12 months. This will produce a major reduction in the lab’s ability to provide timely service for outpatients/inpatients. The Epilepsy Surgery Program has a major role in a partnership with the QEII Foundation to completely renew the Epilepsy Monitoring Unit (EMU) and expand the capacity from the current 2 beds to 4 beds. Drs. Sadler, Clarke (Neurosurgery), and Susan Rahey visited the EMUs at Yale University (New Haven, Connecticut) and Mayo Clinic (Rochester, Minnesota) to assess their physical plant and patient safety features. The plan is to incorporate some of these features into our expansion plans. Fundraising efforts commenced in 2013. A series of presentations to potential donors commenced in 2013 and continue in 2014. The demands for admission to the monitoring unit continue to escalate with wait times now in the 18-24 month range. The weekly Epilepsy Rounds, chaired and organized by Dr. Mark Sadler, continue with major patient management decisions made at case presentation rounds and literature reviews during Journal Club. There is excellent participation from all members of the adult and pediatric epilepsy groups. The Capital Health EEG Laboratory had a complete change and upgrade in the technologies (hardware, software) for EEG recording. One major addition is the ability to record high definition video synchronously for all patients.

New Programs, Partnerships & Innovations Dr. Cory Jubenville joined the division as a part time member with an affiliation with Dr. Roger McKelvey in Dartmouth. He has brought his expertise to assist in managing patients in the Dalhousie Multiple Sclerosis Research Clinic and also is offering support to the Division of Medical NeuroOncology Service for assistance in the management of patients with general neurologic issues. He has also added capacity by providing community based electrodiagnostics in EMG. Dr. Richard Leckey has relocated his divisional clinic from the Cobequid Centre to the Halifax Infirmary site with his special expertise in the expanding volume of epilepsy patients. Dr. Richard Leckey obtained his license for Prince Edward Island in order to conduct clinics on a periodic basis. He did this through the spring and summer of last year to assist Dr. Amanda Fiander to get her practice started in Charlottetown. Efforts are being undertaken to recruit neurologic consultants for the Island. Dr. Bernd Pohlmann-Eden continues to develop the Halifax First Seizure Clinic (HFSC) which evolved to three half day outpatient clinics. Constant streamlining and optimizing of the service, regular weekly team meetings, careful triaging, and regular re-adjustment and revamping of clinic schedules, tracking all new referrals from receipt date and time to completion of triage processing time, became critical to allow new referrals to be seen within the targeted triage time. Dr. Bernd Pohlmann-Eden and Karen Legg, NP, routinely offer extra clinic days to meet their ultimate goal that patients with first seizure will be assessed in a timely manner. A prospective database was further developed (maintained by Research Associate, Dr. Candice Crocker). This model of the First-Seizure Clinic has been recognized and acknowledged. Dr. PohlmannEden has received several invitations nationally and

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Clinical Activity

DIVISION OF NEUROLOGY

internationally to introduce this concept to other centers. Dr. Bernd Pohlmann-Eden and his team continued to use new assessment instruments for the Co- morbidity Clinic to prescreen for anxiety, depression and cognition problems, which will be tested as a pilot study from 2013 to 2014. He is currently working on a new concept with the Head of Psychiatry, Dr. Nick Delva, as the Medical Liaison service is no longer able to cover the monthly Co-morbidity Clinic. Together with Dr. Matthias Schmidt from Neuroradiology, he is continuing to cooperate with Dr. Andrea Bernasconi, from the Montreal Neurological Institute with a focus on post processing analysis of MRIs in patients with epilepsy. He further strengthened a strong cooperation with Dr. Fernando Cendez in Campinos, Brazil.

Collaboration with the Nova Scotia Department of Health & Wellness The Capital Health Stroke Program is one of seven district stroke programs comprising the NS Stroke System. The program aims to implement, sustain, and monitor the Canadian Best Practice Recommendations for Stroke Care throughout Capital Health. The program is managed by Richard Braha, Manager of the Acquired Brain Injury Program, with assistance from Wendy Simpkin, Stroke Program Coordinator, and Christine Christian, Data Analyst. The physicians affiliated with the program are Drs. G. Gubitz and S. Phillips, Division of Neurology, and Dr. A. Mountain, Division of Physical Medicine and Rehabilitation. Dr. Phillips is a Clinical Advisor for Cardiovascular Health NS, which oversees the Provincial Stroke System. The Dalhousie Multiple Sclerosis Research Unit (DMSRU) has been caring for patients and families with multiple sclerosis (MS) for over 35 years. DMSRU is an integrated clinical care and research program within the Division of Neurology at Capital Health. The DMSRU mandate is to provide expert-level evidence-based clinical care, be a leader in-patient advocacy, conduct research, and provide educational opportunities (for patients, families, health care providers, and the general public). The team of physicians, nurses, allied health care providers, and researchers work collaboratively in all areas of the program, thus enhancing the patient experience as well as creating a positive team environment. In collaboration with the MS Society Atlantic Division and Atlantic MS Nurses, the team launched a telephone based education/ support group. At the monthly call-in meetings a health care professional with experience in MS gives a brief presentation on a specific MS related topic and then facilitates open discussion with the group. Currently, there are more than 4,000 patients registered at the DMSRU. In the past year the team had over 2,300 patient visits representing 2,100 unique patients of which over 90% are from Nova Scotia. DMSRU is comprised of

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the Halifax and Sydney sites. The continued increase of the patient population and patient visits is directly linked to the increase in incidence/prevalence of MS in Nova Scotia and to the increasing needs of the MS population. In the past year alemtuzumab, dimethyl fumarate, and teriflunomide were approved by Health Canada for the treatment of relapsing multiple sclerosis. Furthermore, the research pipeline is rich with new agents being studied for both relapsing and progressive MS. DMSRU continues to collaborate with researchers locally, nationally and internationally on research projects spanning a variety of research domains including epidemiology, quality of life, disease modifying and symptom therapies, health economics, and basic science. Presently DMSRU is collaborating in numerous industry funded studies as well as studies funded by CIHR, EndMS Network, and MS Society of Canada.

Average Length of Stay

Dr. Sultan Darvesh presented a Quality of Care Report for the Division of Neurology at the Department of Medicine meeting on May 15, 2014. The title of his presentation was “Normal pressure hydrocephalus: Set the record straight case series review”. The M&M Committee (chaired by Dr. Gord Gubitz) meets on a monthly basis. Divisional members are encouraged to attend, as are Resident Staff, Medical Students and Specialty Nurse Practitioners. Attendance is recorded. Minutes of the previous Rounds are reviewed, and any actions resulting from the previous minutes are discussed. Prior to each meeting, members of the Division are encouraged to submit specific morbidity and process of care issues to the Chair. These are reviewed in detail at the Round, and areas requiring specific action are identified and assigned. Most of the persons who die do so while on the Stroke Unit – these deaths are expected. Therefore, prior to each M&M meeting, the Chair reviews all mortality cases to ensure that all of the documentation has been appropriately completed. The Chair also determines whether there are specific issues arising from the deaths that are not expected during the palliative care process. These specific cases are then brought up for discussion at the Round. Relevant neuro-imaging studies are also reviewed. Minutes generated from the M&M rounds are prepared pursuant to the Evidence Act of NS. S. 60(2) and Freedom of Information and Protection of Privacy Act of NS. S. 19D (1) as amended. The minutes are circulated to the Division M&M Committee Members, and to the Department of Medicine Professional Appraisal Committee. In addition, the Inpatient Care Team meets on a monthly

basis to discuss the day to day operation of the Acute Stroke Unit and when indicated, the General Neurology Service. Specific instances related to the quality and safety of patient care are discussed at this venue. These discussions are used to inform the M&M process, and to respond to suggestions brought forth at the M&M Rounds. The HSFC (Halifax First Seizure Clinic) meets weekly for quality assurance (to constantly review the referral process, waiting time, data bank and developing partnerships.

The inpatient average length of stay for the Neurology Service during the timeframe 2013-14 was 13.1 days. This is a massed average and many diagnostic categories have their own specific average length of stay. Upon review of the data there does appear to be some opportunities to improve efficiencies. The neurology care teams (Stroke and General Neurology) intensively review each patient on daily rounds to determine opportunities to expedite investigations, management and discharge. This includes comprehensive team meetings of all care givers to get maximum input on patient details. There did appear to be some systemic issues leading to delays, such as, availability of technology (delays in obtaining MRI scans) and availability of transfer beds in the Rehabilitation Service. On a daily basis the service chief (Dr. C. Maxner) meets with the 8.1 nursing administrative team to review recent admissions and opportunities for discharge. At times, if there are significant pressures on the neurology service Dr. Maxner will contact the affiliated services to try to arrange expeditious transfer of patients off the neurology service or assistance from other teams, such as, General Internal Medicine (MTU Service), to undertake the care of some of the neurology patients as the patient load on the neurology service becomes excessive. The institution has undertaken a program of obtaining daily information on each patient and, in particular, trying to articulate the reasons why a patient cannot be transferred or discharged. This data is available through the Utilization Management Program. Presentations have been made to the Division of Neurology by the Utilization Management Coordinator, Mr. Hans Lafford. He has been analyzing the data for the neurology service and has put forward documents which will be used in discussion in the summer period of 2014 to identify potential etiologies for delays in patient discharge and transfer. Once these areas of concern can be identified, a rational approach to correcting the problems can be undertaken by the care teams. This is an ongoing process and consists of the participation of service team members, such as the Service

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Quality & Patient Safety

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Chief, Dr. Charles Maxner, the Stroke Director, Dr. Stephen Phillips, the Residency Program Director, Dr. Gordon Gubitz along with the Nursing Unit Manager. We will also be obtaining consultative direction from the directors of the Medical Teaching Unit who have done a similar date analysis on their inpatient service. It would be hoped, with some adjustments in discharge practice, the service will be able to provide all of its care on the 8.1 30 bed unit and significantly reduce the ALC bed days and off service bed days. This also should lead to reduction in average length of stay.

Public Education For each new patient seen in the First Seizure clinic by Dr. Bernd Pohlmann-Eden and Karen Legg, NP, a First Seizure Clinic pamphlet is provided. This gives the patient information on the team members who will be involved in their case, what diagnostic steps may be included in their visit, what to do to prepare for their visit to the clinic and the plan on a go forward basis for each patient. Newly diagnosed patients seen through the MS Dalhousie Research Unit clinic receive an individualized comprehensive education session regarding MS and its potential therapies under the leadership of Mike Kehoe, RN. Virender Bhan, Roger McKelvey, Trudy Campbell, and Mike Kehoe give educational talks to various MS Chapters in Nova Scotia and help the MS Society (Atlantic division) with educational events on MS. The topics range from symptom management, disease modifying therapies, utility of MRI, psychosocial aspects of MS and cognitive issues. There are MS Information and Support Teleconferences the 2nd Wednesday of every month (excluding June, July, and August). The participants dial in to discuss current topics in multiple sclerosis care and research. This is available throughout Atlantic Canada and the sponsors are the Multiple Sclerosis Society Atlantic Division and MS Nurses Atlantic Canada. Once a patient has been prescribed a disease modifying therapy (DMT), they are provided with a one-to-one education seminar in order to learn the proper injection technique and management of long-term injection therapy. We encourage a spouse, family member, or care partner to be in attendance to learn this skill in order to assist the patient as necessary. The Dalhousie Multiple Sclerosis Research Unit (DMSRU) has several patient education/support initiatives in place which includes New to MS Support Group, the DMSRU Facebook page, updated DMSRU website and wellness focused education seminars.

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Department of Medicine Compendium of Divisional Activity 2013-2014 — divisIon of NEUROLOGY

Issues of Appropriateness of Care In August 1998 the Nova Scotia Department of Health began to provide funding for four Disease Modifying Therapies (DMTs) used in the treatment of MS. The funding provided for these drugs is for Nova Scotia residents who do not have private drug insurance coverage and who meet specific disease state criteria. For patients who have private insurance coverage for these agents co-payments for new drug therapies are reimbursed provided the patients meet the provincial drug program criteria. Patients prescribed a DMT are required to attend a one-to-one education seminar (1-2 hours) with the MS Nurse. In these education sessions, patients and family members are presented with information about MS and its treatments. Patients are contacted by the nurse in 1-2 weeks time to further discuss treatment options. Drs. Gubitz and Phillips consult with family members of stroke patients regarding the level of care that is appropriate. There is a designated room which is set up specifically for palliative care of 8.1 patients. If a consult comes through from ED the Staff Neurologist on call will make the decision of whether the consult is truly a neurology related consult or should be referred to another service.

Inpatient Services

Neurologists provide Emergency coverage, inpatient, ambulatory and neuro-diagnostic clinical services

24 hours / day, 7 days / week attending / on-call physician coverage provided to the 30 bed Neurology inpatient unit (HI 8.1) which includes Stroke and General Neurology patients. The average bed utilization for the year 2013-14 was 28.7 beds compared to 29.8 in 2012-13. Average bed utilization and occupancy rates are shown in the following figures:

Specialized neurological care for patients in Capital Health and tertiary care for the province including: •• Electroencephalography (EEG) Lab

•• Epilepsy Program

Figure 2 Neurology Inpatient Bed Occupancy Rate by Fiscal Year QEII Health Sciences Centre, 2009 - 2014

Figure 1

•• Electromyography (EMG) Lab

The occupancy rate decreased to 97.4% in the year 201314. The number of admissions increased in 2013-14 to 761 compared to 690 in the year 2012-13. The average length of stay (ALOS) has decreased to 13.1 days in 2013-14.

120%

Neurology Average Bed Utilization by Fiscal Year QEII Health Sciences Centre, 2009 - 2014

100%

•• Multiple Sclerosis •• Neuro-Ophthalmology Clinic

Percent Occuupancy

35

30

80%

99.5%

98.1%

2010-2011

2011-2012

101.2%

97.4%

88.0%

60%

40%

Beds

•• Behavioral Neurology Clinic

20%

25

•• Neuromuscular Clinic

0% 2009-2010

•• Neuro-Oncology Clinic

2012-2013

Source: STAR Data

20 Used Avail

•• Neurovascular Clinic

Source: STAR Data

•• General Neurology Clinic

2009-2010 25.8 29.2

2010-2011 29.2 29.3

2011-2012 28.9 29.4

2012-2013 29.8 29.5

2013-2014 28.7 29.5

2013-2014

Prepared by DOM Information Office

Figure 3

Prepared by DOM Information Office

Neurology Inpatient Admissions by Fiscal Year QEII Health Sciences Centre, 2009 - 2014 800

•• Movement Disorder Clinic

700

•• Huntington’s Clinic

747

719

761

737 690

Admissions

600

•• Halifax First Seizure Clinic

500 400 300

Emergency Coverage

200 100

Neurologists provide 24 hour, 7-day emergency and on-call coverage for patients in the province.



0 2009-2010 Source: STAR Data

2010-2011

2011-2012

2012-2013

2013-2014

Prepared by DOM Information Office

Department of Medicine Compendium of Divisional Activity 2013-2014 — divisIon of NEUROLOGY

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DIVISION OF NEUROLOGY

Clinical Services

Figure 5 Neurology Inpatient Average Length of Stay (Days) by Fiscal Year QEII Health Sciences Centre, 2009 - 2014

Alternate Level of Care Days Neurology (8.1) Service (Stroke & General) 2011 - 2014

16 14

600

Dayss

530 427 431

3373

2009-2010

A

O

D

F

Apr 2012

164

250

259

189

200

190

269

273

311

291 J

A

O

Source: Manual

2013-2014

Prepared by DOM Information Office

D

F

Apr 2013

J

A

Inpatient Consultations Inpatient consultation service is provided by neurologists to other services at the Halifax Infirmary and VG sites. 424 patients were seen in consultation over the previous year. Consultations have increased in acuity and complexity.

0 J

2012-2013

Source: STAR Data

50 Apr 2011

2011-2012

0

216

234 214

100

2010-2011

8

2

146 175 170 180

276

301 270

336 327

179 169 196

150

245

250

298

306

300

3661

350

13.1

4

382

400

12.9

6

494 451

450

12.8 10.7

10

500

200

14.1

12

550

ALC Dayss

O

D

F

Prepared by DOM Information Office

Figure 6 Neurology Inpatient Consults QEII Health Sciences Centre, 2009 - 2014 700 600 588 # Consults

DIVISION OF NEUROLOGY

Figure 4

500

500 426

400

446

424

300 200 100 0 2009-2010 Source: Manual Data

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Department of Medicine Compendium of Divisional Activity 2013-2014 — divisIon of NEUROLOGY

2010-2011

2011-2012

2012-2013

2013-2014

Prepared by DOM Information Office

Neurologists provided specialized neurological consultation for 7,094 outpatients in 2013-14, including General Neurology patients and specialized clinics for Multiple Sclerosis, Neuromuscular, Neurovascular, Behavioral Neurology and Epilepsy. 25.1% of the visits were new patients whereas 74.9% were return patients. The presence of more specialized neurology clinics equates to higher return rates. An additional 384 patients were seen in Neuro-Ophthalmology and Neuro-Oncology clinics. There were an additional 1,250 chart checks performed in 2013-14 not included in the following figures.

Wait times for general neurology outpatient visits as well as subspecialty clinics are shown in the following graphs by triage category. Referrals to the General Neurology clinic and to the subspecialty clinics were all seen within the recommended standards.

Table 1

Figure 8 Apr 11 108 225 191 59 88 682 8 30 38

May 5 126 204 159 32 75 601 13 36 49

Jun 11 89 221 165 64 60 610 9 19 28

Jul 9 104 207 194 50 90 654 0 28 28

Aug 6 62 125 101 19 87 400 0 26 26

Sep 12 88 181 134 46 87 548 0 30 30

Oct 10 89 277 169 56 67 668 0 35 35

Nov 12 100 276 148 41 70 647 0 27 27

Dec 8 53 186 118 45 49 459 0 27 27

Jan 7 107 242 135 44 79 614 0 35 35

Feb 6 92 235 162 53 68 616 0 35 35

Mar 6 86 253 141 40 69 595 0 26 26

Total 103 1,104 2,632 1,817 549 889 7,094 30 354 384

Total

720

650

638

682

426

578

703

674

486

649

651

621

7,478

Source: Star Data Prepared by DOM Information Office

General Neurology Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014 16

12

8

Days

Clinic Behavioral Neuro Epilepsy Multiple Sclerosis Neurology Neuromuscular Neurovascular Subtotal Neuro Oncology Neuro Ophthal Subtotal

4

0 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard

Q1 12-13 7.1 14 27 1 17 89%

Q2 12-13 9.8 14 9 2 45 89%

Q3 12-13 8.3 14 12 0 23 83%

Q4 12-13 3.6 14 10 1 9 100%

Q1 13-14 7.6 14 9 3 14 100%

Source: PHS Data

Q2 13-14 5.8 14 10 0 17 90%

Q3 13-14 6.9 14 10 2 13 100%

Q4 13-14 5.1 14 11 2 12 100%

Prepared by DOM Information Office

Figure 9

Figure 7

General Neurology Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014

Neurology New and Return Ambulatory Care Registrations QEII Health Sciences Centre, 2009 - 2014

200

8,000

150

Days

Registrations

6,000

100

4,000

50 2,000

0 CodeMissing New Return Total % New Source: STAR Data

0

2009-2010 444 1,721 4,833 6,998 24.6%

2010-2011 388 1,725 4,618 6,731 25.6%

2011-2012 283 1,822 5,212 7,317 24.9%

2012-2013 281 1,760 5,179 7,220 24.4%

2013-2014 444 1,779 4,871 7,094 25.1%

Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard Source: PHS Data

Q1 12-13 151.0 182 125 0 636 69%

Q2 12-13 137.5 182 116 1 517 65%

Q3 12-13 137.5 182 142 0 420 65%

Q4 12-13 134.9 182 124 0 374 75%

Q1 13-14 139.3 182 182 0 420 65%

Q2 13-14 143.7 182 152 2 472 64%

Q3 13-14 126.4 182 143 1 494 80%

Q4 13-14 100.3 182 162 1 455 82%

Prepared by DOM Information Office

Prepared by DOM Information Office



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DIVISION OF NEUROLOGY

Ambulatory Care

Figure 12

Neurology Multiple Sclerosis Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014

Figure 14 Neurology Epilepsy Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014

Neuromuscular Semi-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014

200

200

80

180

180

160

160

60

140

140

80 60

Days

120

100

Days

Days

120

40

80 40

20 0 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard

100 60

20

40

20 Q1 12-13 45.1 182 29 1 145 100%

Q2 12-13 31.0 182 39 0 169 100%

Q3 12-13 42.7 182 37 0 161 100%

Q4 12-13 66.5 182 34 1 253 88%

Q1 13-14 57.0 182 22 0 156 100%

Source: PHS Data

Q2 13-14 69.4 182 33 1 254 97%

Q3 13-14 80.6 182 50 2 312 96%

Q4 13-14 74.3 182 32 0 243 94%

Prepared by DOM Information Office

Figure 11

0 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard

Q1 12-13 44.0 56 3 28 56 100%

Q2 12-13 64.0 56 1 64 64 0%

Q3 12-13 43.3 56 3 26 61 67%

Q4 12-13 18.0 56 1 18 18 100%

Q1 13-14 27.3 56 4 5 67 75%

Source: PHS Data

Q2 13-14 34.5 56 2 26 43 100%

Q3 13-14 15.0 56 1 15 15 100%

56 0

Prepared by DOM Information Office

Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard

Q1 12-13 136.0 182 81 6 435 48%

Q2 12-13 163.8 182 56 5 402 55%

Q3 12-13 154.2 182 79 1 292 52%

Q4 12-13 129.7 182 91 1 315 76%

Q1 13-14 119.9 182 63 0 420 92%

Source: PHS Data

Q2 13-14 116.9 182 61 1 244 79%

Q3 13-14 142.7 182 65 2 233 89%

Q4 13-14 151.0 182 76 2 264 42%

Prepared by DOM Information Office

Figure 15 Neurovascular Emergent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014

Neuromuscular Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014

200

0

Q4 13-14

Figure 13

Geriatric Behavioural Clinic Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014

4

200 180 160

150

Source: PHS Data

140

100 80 60

50

Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard

Days

100

0

3

140 120 Days

Days

DIVISION OF NEUROLOGY

Figure 10

1

40

Q1 12-13 141.9 182 19 0 380 79%

Q2 12-13 145.0 182 23 49 339 87%

Q3 12-13 122.2 182 27 24 180 100%

Q4 12-13 124.3 182 32 11 971 97%

Q1 13-14 92.6 182 30 25 278 97%

Q2 13-14 106.9 182 26 25 175 100%

Q3 13-14 109.5 182 21 11 224 95%

Q4 13-14 90.2 182 27 7 151 100%

Prepared by DOM Information Office

20 0 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard Source: PHS Data

Department of Medicine Compendium of Divisional Activity 2013-2014 — divisIon of NEUROLOGY

2

Q1 12-13 185.7 182 67 10 461 43%

Q2 12-13 174.4 182 46 18 277 46%

Q3 12-13 173.3 182 53 34 271 49%

Q4 12-13 171.1 182 65 19 322 48%

Q1 13-14 148.4 182 65 13 257 55%

Q2 13-14 154.9 182 48 2 287 63%

Q3 13-14 169.1 182 59 1 340 49%

Q4 13-14 181.0 182 65 7 713 42%

Prepared by DOM Information Office

0 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard Source: PHS Data

Q1 12-13 1.5 2 2 1 2 100%

Q2 12-13 3.0 2 1 3 3 0%

Q3 12-13 2.0 2 4 2 2 100%

Q4 12-13 1.0 2 2 0 2 100%

Q1 13-14 2.0 2 1 2 2 100%

Q2 13-14 1.3 2 7 0 2 100%

Q3 13-14 1.0 2 1 1 1 100%

Q4 13-14 1.4 2 8 0 2 100%

Prepared by DOM Information Office

Neurodiagnostic Laboratories

Figure 18 Neurovascular Non-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014

Neurovascular Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014

Staff in highly specialized neurodiagnostic laboratories at the Halifax Infirmary Site performed 1,377 EEG and 1,693 EMG studies during the 2013-14 fiscal year.

200

15

180 160 140

10 Days

Days

120

The wait time for non-urgent outpatient EEGs was 8 weeks at the end of March 2014. The wait time for non-urgent EMG studies was 28 weeks at the end of March 2014

100 80

5

60 40 20

0 Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard

Q1 12-13 6.4 14 30 0 14 100%

Q2 12-13 6.8 14 17 2 15 94%

Q3 12-13 6.6 14 17 1 13 100%

Q4 12-13 7.5 14 26 1 23 85%

Q1 13-14 6.8 14 20 1 14 100%

Source: PHS Data

Q2 13-14 9.9 14 17 4 44 94%

Q3 13-14 7.3 14 12 3 15 83%

Q4 13-14 8.9 14 21 3 16 95%

Prepared by DOM Information Office

Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard Source: PHS Data

Q1 12-13 79.6 182 30 7 160 100%

Q2 12-13 62.7 182 71 0 152 100%

Q3 12-13 62.7 182 87 0 189 99%

Q4 12-13 65.5 182 95 6 147 100%

Q1 13-14 61.8 182 37 2 169 100%

Q2 13-14 101.9 182 57 5 302 96%

Q3 13-14 99.3 182 44 0 169 100%

Q4 13-14 105.4 182 32 15 293 97%

Increased wait times are a result of technician shortages within our compliment. We are attempting to address this by hiring two trainees, but this will not increase productivity for a minimum of one year.

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EEG volumes do not include video-EEG telemetry recordings which require significantly more technician and physician interpretation time. There were 342 Video Telemetry bed days.

Figure 17 Neurovascular Semi-Urgent New Consult Ambulatory Care Clinic Average Wait Time (Days) by Quarter QEII Health Sciences Centre, 2012 - 2014 60

Figure 19

50 40 Days

0

Electroencephalograms (EEG's) Performed QEII Health Sciences Centre, 2009 - 2014

30

2,000

20 10

Average Wait Time Standard Wait Time Count Minimum Wait Maximum Wait % Within Standard Source: PHS Data

1,600 Q1 12-13 26.5 56 22 2 70 95%

Q2 12-13 40.0 56 23 2 81 74%

Q3 12-13 17.0 56 2 16 18 100%

Q4 12-13 18.4 56 5 6 29 100%

Q1 13-14 35.4 56 38 2 64 87%

Q2 13-14 46.2 56 47 5 145 70%

Q3 13-14 32.2 56 26 2 65 88%

Q4 13-14 35.5 56 33 5 92 94%

# EEG's

0

1,200

800

400

Prepared by DOM Information Office

0 In-patient Out-patient Total Source: Manual Data



2009-2010 369 1,194 1,563

2010-2011 306 1,116 1,422

2011-2012 317 1,250 1,567

2012-2013 299 1,186 1,485

2013-2014 307 1,070 1,377

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Department of Medicine Compendium of Divisional Activity 2013-2014 — divisIon of NEUROLOGY

141

DIVISION OF NEUROLOGY

Figure 16

Figure 21

Electromyograms (EMG's) Performed QEII Health Sciences Centre, 2009 - 2014

Figure 22

Out-Patient Wait Times for a Non-Urgent EEG 2012 - 2014

2,500

Out-Patient Wait Times for a Non-Urgent EMG 2012 - 2014 30

9 8

2,000

25

7 6

1,500

# Weeks

1,000

20

5

# Weeks

# EMG's

4 3

15

10

2

500

5

1 0 In-patient Out-patient Total

2009-2010 165 1,506 1,671

2010-2011 165 1,402 1,567

2011-2012 148 2,035 2,183

Source: Manual Data

2012-2013 121 2,183 2,304

2013-2014 112 1,581 1,693

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0

Apr Apr M J J A S O N D J F M M J J A S O N D J F M 12 13 Average Wait Time 2 3 3 4 4 6 5 5 3 4 4 3 4 3 4 4 4 6 4 2 4 6 5 8 Standard Wait Time 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Source: Manual/PHS Data

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0

Apr Apr M J J A S O N D J F M M J J A S O N D J F M 12 13 Average Wait Time 15 16 16 15 15 16 14 18 17 20 18 21 22 19 21 24 23 24 27 26 24 28 27 28 Source: Manual/ PHS Data

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Patient Residency Distribution of patient residency is shown, with the majority of patients from the Capital District (84.5% of inpatients and 64.0% of outpatients). This reflects the demographics of the province and supports the need for access to subspecialized neurology outpatient clinics. Figure 23

Figure 24

Figure 25 Neurology Average Wait Time - Consult Request to Admit Ordered Capital Health, 2009 - 2014

Neurology Clinic Registrations Distribution of Patient Residency by Health District QEII Health Sciences Centre, 2013 - 2014

Neurology Inpatient Admissions Distribution of Patient Residency by Health District QEII Health Sciences Centre, 2013 - 2014

Guysborough Antigonish Strait: 112

Cape Breton: 3

6

Cape Breton: 98

Average Wait TTime - Consult Request to Adm mit Ordered (hrs)

DIVISION OF NEUROLOGY

Figure 20

Pictou County: 231 Cumberland: 127

Guysborough Antigonish Strait: 7

Colchester East Hants: 527

Pictou County: 9 Cumberland: 10 Colchester East Hants: 36 Annapolis Valley: 15

Capital: 643

South West Nova: 4 South Shore: 10

Annapolis Valley: 507 Capital: 4,537 South West Nova: 315

Out of Province: 15 NB, NF, PEI: 9

South Shore: 305

142

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Source: STAR Data

Department of Medicine Compendium of Divisional Activity 2013-2014 — divisIon of NEUROLOGY

4 3 2 1 0

0800-2300 2300-0800 Benchmark Volume 0800-2300 Volume 2300-0800

Out of Province: 335

Source: STAR Data

5

Prepared by DOM Information Office

Source: EDIS

2009-2010 3.4 3.0 2 461 116

2010-2011 3.3 2.8 2 437 115

2011-2012 3.2 3.5 2 475 124

2012-2013 3.7 3.5 2 464 113

2013-2014 3.3 3.8 2 371 89

*2300-0800 consult 300 0800 and a d 0800-2300 0800 300 aaree based oon co su t request equest ttimes. es *Times included when the consulting service is also the admitting service Prepared by DOM Information Office

Neurologists provided approximately 350 hours of medical education to undergraduate and postgraduate trainees in 2013-14. Undergraduate Medical Education Dr. Ian Grant continues to serve as Unit Head for the Neuroscience and Special Senses Unit in Undergraduate Medical Education. Dr. Grant also has responsibility for the Clinical Skills Program in Bedside Neurology Teaching for the Med 2 students. •• One Med 1 & 2 elective rotation was completed in Neurology in 2013-14, with the addition of 2 two-week Pre-Med 3 IMU Hospital Experience Rotations. •• 23 four-week Med 3 rotations were completed in Neurology.

Postgraduate Medical Education

Sub-specialty Medical Education

The postgraduate program under the leadership of Dr. Gord Gubitz remains active in conducting numerous education sessions for the residents as well as providing superb clinical training. Three PGY 5 residents (Drs. Cory Jubenville, Colin Josephson and Heather Rigby) successfully completed their Royal College Examinations in Adult Neurology in May 2013.

Our program continues to attract top quality and highly sought after candidates in the CaRMS PGY1 match. Last year we matched Dr. Benjamin Whatley (CaRMS). In addition, Dr. Sondos Al-Hindi and Dr. Adnan Badahdah also joined the Residency Training Programme (VISA Trainees). Drs. Whatley, Al-Hindi and Badahdah started as our new PGY1 residents as of July 1, 2013.

20 residents from the following programs rotated through the neurology service from July 1, 2013 to June 30, 2014:

Continuing Medical Education Sixty-three lectures were provided by numerous division members during continuing medical education events locally, provincially, nationally and internationally.

•• Psychiatry •• Anesthesia

The division welcomed 13 visiting professors in 2013-14.

•• Physical Medicine & Rehabilitation

•• 26 two-, three- or four-week Med 4 elective rotations were completed in Neurology in 2013-14. •• Division members completed 8 hours as preceptors for Med 1 Rotating Electives, 72 hours of Med 2 CaseBased Learning (CBL): Foundations and Neurosciences, 210 hours as Tutors in the Med 2 Neuro Clinical Skills section in 2013-14. •• Division members provided 13.75 hours to Med 2 OSCE exams in 2013-14.

Division members recorded their attendance at 23 continuing medical education seminars or meetings in 2013-14.

•• Urology •• Ophthalmology 33 Core Internal Medicine residents rotated through the neurology services in the 2013-14 academic year. Neurologists presented 9 hours of lectures at Internal Medicine Academic Half Day in 2013-14.

•• Division members provided 20 hours of lectures to the Med 2 Wednesday afternoon seminars and Dr. Ian Grant presented a 2 hour refresher course on the Neuro exam to the IMU link students



Department of Medicine Compendium of Divisional Activity 2013-2014 — divisIon of NEUROLOGY

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Education

DIVISION OF NEUROLOGY

Research The Division generated $253,160 in research grants and $551,899 in industry contracts during 2013-14 for a total of $805,059. Some highlights include: •• Dr. Bernd Pohlmann-Eden is the Principal investigator of a randomized control trial of Lacosamide versus carbamazepine in new-onset epilepsy. He was awarded several educational grants from research agencies, research facilities of Dalhousie University (eg. Brain Repair Center), and pharmaceutical companies (eg. UCB Pharma Canada) in order to prepare the 3rd Halifax International Epilepsy Conference & Retreat on Cognition and Psychiatric comorbidities in new-onset epilepsy which will take place in September 2014.

Administration •• Dr. S. Darvesh does research involved in medicinal chemistry, biochemistry, chemoarchitecture and clinical aspects of Alzheimer’s disease and related disorders. In 2013/2014 he published 4 papers in highly regarded journals. His work was presented at 10 National and International conferences. He holds 1 CDHA grant, 1 BRC grant, 1 CIHR grant, 1 Innovacorp grant and 1 SDU2020 grant from Syddansk University. He was issued 3 new patents as Principal Inventor. Dr. Darvesh continues as the Director of The Maritime Brain Tissue Bank. •• Division members supervised 9 students in support of their research projects.

•• Dr. Bernd Pohlmann-Eden was also awarded a research grant by the patient organization Epilepsy Association Nova Scotia to allow prescreening of anxiety and depression in patients who are assessed for their first seizure. •• The Neurovascular Research Group (Drs. Stephen Phillips, Gordon Gubitz, Gwynedd Pickett, Division of Neurosurgery, and Jai Shankar, Division of Neuroradiology) is participating in investigatorled randomized trials of stroke prevention and treatment funded by NIH, CIHR, and Heart and Stroke Foundation. The group is also participating in a new Canadian-led study attempting to improve rapid access to interventional thrombolysis for acute ischemic stroke.

Neurologists perform the following administrative activities: •• Division Head, including all responsibilities of the position. •• Service Chief and Deputy Service Chief duties for inpatient services. •• Division members act as Medical Directors for: –– –– –– –– –– –– –– –– –– –– –– –– –– –– ––

Stroke and General Neurology Services General Inpatient Neurology Consultation Services EEG and EMG Laboratories Dalhousie MS Research Unit Neurovascular Clinic Epilepsy Clinic Epilepsy Transitional Clinic Halifax First Seizure Clinic Behavioral Neurology Clinic Movement Disorders Clinic Huntington’s Disease Clinic Neuromuscular Clinic Neuro-ophthalmology Clinic Research Neurology Program Director (Neurology Subspecialty and Medicine Postgraduate and Undergraduate Education)

•• Divisional members assume a leadership role in administration by participating in: –– –– –– ––

Hospital committees Department committees University committees Affiliated local, regional, national and international organizations

Division members provided referee or editorial services to 64 journals and 23 granting agencies in 2013-14. 144

Department of Medicine Compendium of Divisional Activity 2013-2014 — divisIon of NEUROLOGY