Toronto Rehab Magazine Summer 2010

SUMMER 2010

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E V E R Y T H I N G

H U M A N L Y

Helping Haiti

P O S S I B L E

Toronto Rehab’s humanitarian mission

Contents

4 Managing spasticity

An interprofessional approach

6 Saving your skin

How to prevent pressure ulcers

8 Dr. Alex Mihailidis

Intelligent homes pioneer

10 Toronto Rehab news

Accreditation, awards and more

12 High-tech hand hygiene

Preventing hospital-acquired infections

15 Disability and rehab

Lessons of a cheese sandwich

16 Post script

Julia Brimo’s challenge of a lifetime

The Toronto Rehabilitation Institute is at the forefront of one of the most important and emerging frontiers in health care today—rehabilitation science. As the University of Toronto’s fully affiliated teaching and research hospital in adult rehabilitation, complex continuing care and longterm care, our goal is to revolutionize rehabilitation and maximize life for the 4.4 million Canadians who experience disabling injury and illness.

Toronto Rehab magazine Summer 2010, Volume 10, Number 1 Inquiries and requests to reprint/ return undeliverable Canadian addresses to: Marketing & Communications, Toronto Rehab 439 University Avenue, 5th Floor Toronto, Ontario, Canada M5G 1Y8 Telephone: 416-597-3422, ext. 3425 E-mail: communications@torontorehab.on.ca Web site: www.torontorehab.com

Editor Production Coordinator/Writer Contributing Writer Design Cover Photo Photography

Jennifer Ferguson Annie Atkinson Chris Atack WymanDesign.ca Lisa Carnie Jim Atkinson / MediMedia Group Mark Ridout Photography Jamie Young / Toronto Rehab Michel Landry / Toronto Rehab patlangphoto.com Printing TI group

Saving lives, r

By Dr. Michel Landry Nothing—not even working and living through post-conflict Bosnia, the wars in Kosovo and Guatemala or post-tsunami Sri Lanka—prepared me for the utter devastation that we found when we arrived as part of Toronto Rehab’s humanitarian mission this spring in earthquakeravaged Haiti.

The January 12, 2010 catastrophic 7.0 earthquake brought the poorest country in the western hemisphere to its knees. Here is a reminder of the grim outcomes of the earthquake that lasted 58 seconds: an estimated 250,000 people died, 300,000 were injured and 1.5 million were left homeless.

Neighbourhoods and families were destroyed and children orphaned; businesses, government offices, public services and many hospitals were in ruins.

The rapid response of medical teams in the hours after the earthquake saved hundreds of thousands of lives, but also created one of the largest cohorts of persons with disabilities in the world. As many as one in four Haitians was left with a disability.

We should all be proud that Toronto Rehab joined the global response to this natural disaster. In a bold and rare move for a hospital, Toronto Rehab’s leadership issued an invitation to staff to participate in a rehabilitation mission to Haiti. I was asked to lead this humanitarian response, and our first team spent two weeks treating victims of the earthquake at Hôpital Albert Schweitzer in Deschappelles, Haiti.

The devastating stories of the people we met broke our hearts, yet gave us hope.

Shortly after we returned to Toronto, a call came from colleagues with a non-governmental organization called Healing Hands for Haiti. Our expertise in spinal cord rehabilitation was needed for patients who had sustained spinal cord injuries when trapped in the rubble of collapsed buildings. Nineteen of these patients had been gathered at a small hospital in the northern community of Cap Haitien. Toronto Rehab had its mission: to care for these patients and to educate Haitian health professionals about spinal cord rehabilitation so they

Cover photo: Toronto Rehab physiotherapist Jamie Young (left) and occupational therapist Tess Devji (centre) with Emania, a Haitian patient with a spinal cord injury.

ebuilding hope in could continue to care for these patients and build their country’s capacity to provide rehabilitation and this type of specialized service.

Dr. Anthony Burns, Medical Director of Toronto Rehab’s spinal cord rehabilitation program, nurse Jackie Wright, physiotherapist Jamie Young and occupational therapist Tess Devji of the spinal cord rehab program joined me on the next two-week trip to Haiti.

As we trudged through the mud toward the remote hospital, I’m sure the team must have been quietly asking, “What have we gotten ourselves into?” But within five minutes of our arrival, I looked around the crowded room with 19 spinal cord injured patients—and I was awestruck.

Tony, Jackie, Jamie, Tess and all the patients and hospital staff had united in a symphony of people working together.

Care was being delivered, therapy was under way and stories were being heard for the first time.

The patients were much less medically stable than we had anticipated.

Without the care we provided, many of these Toronto Rehab Foundation has patients would provided a grant to cover the costs have died from wound infections, of the hospital’s work in Haiti. You and bowel can help Toronto Rehab help Haiti: and bladder complications.

Visit www.torontorehab.com Throughout the spring, our today for a link to our Haiti work in Cap donation website. Also, visit the Haitien blog written by our staff in Haiti at continued. A of truly www.rehabinhaiti.wordpress.com number outstanding teams from Toronto Rehab’s spinal cord rehabilitation program participated in two-week rotations in Haiti to rehabilitate patients and help them rebuild their lives. Our patients are progressing and our Haitian colleagues are learning about spinal cord rehabilitation.

We have much to do to reach long-term solutions for the many people who now live with significant disabilities in Haiti. I know our team members returned from Haiti with new perspectives that will make them even better clinicians for our patients here at home. I know that we all returned better human beings.

Is Toronto Rehab doing the right thing by being involved in the global response in Haiti? Having been to Haiti, seen the devastation and heard the stories from the people, my answer is “absolutely.”

Haiti Above: Destruction from the earthquake in Haitian capital of Port-au-Prince

Above: Dr. Michel Landry (right) and Toronto Rehab nurse Jackie Wright (centre) help to transfer a patient to the hospital.

How you can help

Above: Toronto Rehab’s Dr. Anthony Burns (right) returns from a helicopter flight to accompany a spinal cord injury patient for x-rays.

Left: Dr. Burns provides wound care for a patient and teaches the procedure to Haitian colleagues (not shown in photo).

At press time, Toronto Rehab is exploring other avenues through which it could continue to provide much-needed support to the people of Haiti.

Dr. Michel Landry is a physical therapist, an adjunct scientist at Toronto Rehab and an assistant professor in the Department of Physical Therapy at the University of Toronto. For the past 15 years, Dr. Landry has led humanitarian, development and global health initiatives in many of the world’s most dangerous countries, including Bosnia, Kosovo, Guatemala and Sri Lanka.

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Spasticity

Specialized clinic helps people learn to manage muscle contractions Janice Chu enjoys her independence in the community.

Janice Chu made good progress regaining her mobility and speech at Toronto Rehab’s stroke rehabilitation service following her stroke in the spring of 2009. But the lingering effects of constant muscle tightness in her right arm and leg—called spasticity—kept her from being independent in her senior’s apartment in downtown Toronto. Janice needed help to shower, dress, cook and clean—and even to answer the phone when her sons called to check on her.

When spasticity curled up her right arm tight against her body, it affected Janice’s balance and she was afraid of falling. “I was really sad because I could do nothing,” she recalls.

Fast-forward to the spring of 2010 and the 77-year-old is confident and all smiles.

After individualized therapy and treatment at Toronto Rehab’s year-old Comprehensive Spasticity Management Clinic—including therapy for her upper and lower extremites, the creation of customized splints for her arm and foot, and botulinum toxin injections—Janice’s condition is under better control and her quality of life has improved. She is delighted to be able to reach for and answer the phone, which was one of her goals. She is more independent, needs minimal help at home, and she ventures out into the community to shop and have lunch with friends.

“Everything feels good so I forget about before,” Janice says. “I recommend the clinic to other patients because I’ve

tried it and I know how good it is. I am happy.”

“Spasticity is a persisting issue. By treating it, we don’t make it go away, so we have to help people with spasticity, their caregivers and families learn to manage it,” explains Dr. Denyse Richardson, a Toronto Rehab physiatrist (specialist in rehabilitation medicine) who oversees the clinic.

The Comprehensive Spasticity Management Clinic offers a full range of treatment options: physical and occupational therapy, on-site fabrication of splints and casts, and oral or injectable medications including botulinum toxin injections.

Managing spasticity is challenging and requires an individualized approach by an interprofessional team including the physiatrist, occupational therapist, physiotherapist, nurse, pharmacist, orthotist and a service coordinator. Patients are assessed by the team and a care plan is developed.

“Interprofessional care is integrated care based on a shared management plan,” says Dr. Richardson.

“The best management plan for a patient is based on input from all team members using everybody’s expertise.”

An important part of the care plan involves the patient’s own goals. “Everybody’s goals are different: one person wants to be able to answer the phone, while others want to return to knitting, cook for themselves or play tennis again,” says Parvin Eftekhar, the clinic occupational therapist.

“Everybody’s goals are different: one person wants to be able to answer the phone, while others want to return to knitting, cook for themselves or play tennis again.”

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tissues surrounding a joint and the alignment of the joint itself. Cold weather, fatigue and activity can increase spasticity. The degree and location of spasticity varies for each person; it can range from mild muscle stiffness with minimal impact on functioning, to severe and even painful stiffness or immobility that significantly limits functioning.

Severe spasticity can result in secondary complications, such as skin breakdown.

The Comprehensive Spasticity Management Clinic is an example of Toronto Rehab’s commitment to implementing new models of care that improve patient access and service integration. Dedicated to patient care, education and research, the team integrates best practice into

Practicing answering the phone with Parvin Eftekhar, occupational therapist (left)

“Our team is all on the same page. We know the goals and the therapy plan. There is harmony—we are well orchestrated. We aim to help equip people to manage their own spasticity.”

Dr. Richardson agrees that the “commitment of the team is very exciting. They want to improve the outcomes for patients and move the whole knowledge base of spasticity management forward.”

Spasticity is a disorder of the central nervous system where muscles contract or tighten beyond a person’s control. The disorder is common among people who have had a stroke, multiple sclerosis, cerebral palsy, spina bifida, spinal cord injury, brain injury or other neurological conditions. It interferes with movement, makes it difficult to perform daily activities and can worsen over time.

Prolonged spasticity can result in changes in the soft Exercising with physiotherapist Jeremy Griffiths

Receiving botulinum toxin injection from Dr. Denyse Richardson (left)

rehabilitation care so that patients receive evidence-based treatment.

The clinic serves inpatients referred from Toronto Rehab as well as people referred from the community. For more information and referral forms, contact the clinic’s service coordinator at 416-597-3422, ext. 7009.

Clinic services

————————————————————————— 3 Short-term physical and occupational therapy ————————————————————————— 3 Stretching and exercise programs —————————————————————————

3 Making sure that braces, splints and walking aids are working for the patient ————————————————————————— 3 Making new splints and casts on-site or coordinating with cast and brace makers off-site if necessary ————————————————————————— 3 Helping the patient to walk better and sit more comfortably ————————————————————————— 3 Consulting with other services in the community that can help the patient ————————————————————————— 3 Prescribing medication and giving injections to lessen spasticity ————————————————————————— 3 Teaching the patient how to keep spastic muscles as flexible as possible

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Hong (patient) was admitted to Toronto Rehab with 18 pressure ulcers, which took over a year to heal with care from a team led by Peggie Gairy (right). At centre is Hong’s wife, Helen.

Saving your skin

What people at risk need to know about prevention and treatment of pressure ulcers

When Hong was admitted to Toronto Rehab’s E.W. Bickle Centre for Complex Continuing Care in the spring of 2008, his body was covered with 18 pressure ulcers—also known as pressure sores or bed sores—on his shoulders, tailbone, hips, hand, behind one knee, on the inside and outside of his ankles, on both heels and other parts of his feet.

“This was a very challenging set of wounds to heal because we couldn’t find positions for him in bed that avoided all of his sores,” says Peggie Gairy, a nurse educator and wound clinician.

“Every two hours, day and night, he had to be turned and in the mornings it would Pressure ulcers on the side of Hong’s foot (left) take up to two hours and heel during the healing stage. to do the dressings.”

“They were very bad,” Hong’s wife Helen says of his wounds, which formed over the course of a month when he was back and forth between acute care hospital and a nursing home elsewhere in Toronto.

“At Bickle Centre, they had a special program and they took it 6

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very seriously. They changed his dressings every day, gave him a special mattress and kept turning him to relieve the pressure.”

It took 13 months of diligent care by a highly skilled team of nurses, physicians, physiotherapists, occupational therapists, dietitians, speech-language pathologists and pharmacists to heal Hong’s wounds. Although the now-50year-old has been semi-comatose for six years, caused by cardiac arrest that led to oxygen deprivation to the brain, his wife Helen is greatly relieved that the pressure ulcers have healed. “I feel much more comfortable and happy now. Even if he doesn’t understand what is happening, I don’t want him to feel pain or feel bad.”

“We have become a centre of excellence for looking after people with pressure sores,” says Dr. Ken Uffen, Medical Director of Bickle Centre. In 2009/10, 28% of patients with pressure sores were healed and in any quarter of that fiscal year, 35% to 40% of patients experienced improvement. “This is outstanding given the complexity of some of these wounds and how long they take to heal.”

Pressure ulcers are damage to the skin that is caused by unrelieved pressure over a bony area such as elbows, hips, ankles, shoulder blades and sitting bones. An ulcer can range

from redness to an open wound. Like an iceberg, often the biggest part of the wound is under the surface. Unchecked, infection can spread to the bones, and sepsis or blood poisoning can lead to death.

Pressure ulcers occur mainly in people whose mobility is impaired. If they remain in one sitting or lying position for too long, the oxygen supply to the area can be affected and an ulcer can form. People who have conditions that cause a change in the sense of touch/feeling, such as spinal cord injury, are also at risk.

“Up to 85% of people with spinal cord injury will have a pressure ulcer at some point in their lives,” says Diane Leber, a nurse and the wound clinician in the outpatient wound clinic of the spinal cord rehabilitation program at Toronto Rehab’s Lyndhurst Centre. Other risk factors include: eating a poorly balanced diet, skin getting too moist from long or repeated exposure to urine or stool, sliding down in bed, and surfaces rubbing together such as skin and a toilet seat. Skin breakdown can also be caused by something as simple as a stubbed toe, a scratch or burn.

Diane encourages anyone with a mobility impairment who notices a red area of skin to have it checked immediately by a health professional. “It is important to identify and eliminate the cause of the pressure ulcer while moving ahead with treatment.”

Peggie Gairy, wound clinician and nurse educator, prepares a dressing tray for a wound assessment.

Smart cushion cues user to move Toronto Rehab researchers are seeking funds for clinical trials to test a ‘smart’ cushion that they believe will help avoid suffering by preventing pressure ulcers, potentially save lives and reduce costs to the health care system.

The SensiMat—developed in collaboration with Elmedex, a Torontobased company—is a thin cushion that goes under a wheelchair cushion.

Built-in sensors detect when the wheelchair user “is not sitting properly or forgets to regularly rearrange their sitting position,” explains Dr. Milos R. Popovic, Toronto Rehabilitation Institute Chair in Spinal Cord Injury Research.

The low-cost, high-tech cushion can prompt the user with a light, vibration or audio cue to adjust their seating position. It can even send a reminder call to their cell phone.

Treatment can involve repositioning to keep pressure off the sore; special foam or gel mattresses can be used to redistribute a patient’s weight. Other treatments may include topical medications and antimicrobial dressings, antibiotic medications if the infection spreads beyond the wound, and even surgery.

Good nutrition is another key factor because protein and nutrients are required for the healing process. Smoking is discouraged as it constricts the blood vessels and reduces oxygen supply to the wound.

It can take up to two years for a scar to mature and the healed tissue is only 80% as strong as the original skin.

Pressure ulcers also can have a dramatic impact on a person’s quality of life—affecting their ability to dress themselves, cook, and attend work or school. “Some wounds are odorous and draining, so social isolation can be an issue,” adds Peggie.

The wound clinicians recommend that people at increased risk for pressure ulcers check their bodies for redness, darkened areas, blisters or skin breaks each morning and night. They should change positions in bed at least every few hours, and shift their weight while seated every 15 minutes.

For people who use wheelchairs, they suggest a reassessment of their wheelchair cushions at least every two years.

For more complete information on preventing pressure ulcers, visit: www.npuap.org/PU_Prev_Points.pdf and www.rnao.org/Page.asp?PageID=122&ContentID=817 TORONTO

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Intell!gent homes and other smart technologies Research Chair recognizes Alex Mihailidis as a pioneer in his field Imagine a house that could find your eye glasses, remind you to eat your vegetables, monitor your blood pressure and heart rate as you walk across the bathroom floor, and prompt your 80-year-old mother who has dementia through the process of toileting and washing her hands. And if she fell down, the house could also call for help.

A decade ago, when Alex Mihailidis was a master’s student and came up with the idea of an intelligent home to support people through the various stages of life, even fellow scientists considered the concept far-fetched.

Today, Dr. Mihailidis is a highlyregarded, published researcher and in-demand speaker for major conferences on aging and technology, where there are “all kinds of sessions on this type of work,” he says. “I guess we were ahead of our time.”

Dr. Mihailidis’ pioneering work—inspired by a colleague whose wife had early-onset Alzheimer’s disease—has led him to be named Toronto Rehab’s Barbara G. Stymiest Chair in Rehabilitation Technology Research.

The research chair is “recognition of Alex and the fact that we really believe his field of research has an important future here,” says Dr. Geoff Fernie, Vice President, Research, at Toronto Rehab. “We’re an applied institution, which means we believe that within a reasonable timeframe, this work will have important implications for the people we serve.”

A biomedical engineer and associate professor of occupational 8

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The Helper fall detection system: the ceiling-mounted unit contains a special video camera that measures silhouettes and shadows. If a fall is detected, the unit communicates with the person to determine if assistance is needed.

science and occupational therapy at the University of Toronto, Dr. Mihailidis oversees a group of diverse researchers with backgrounds in engineering, computer science, occupational therapy, speech-language pathology and gerontology. The team’s goal is to develop “zero-effort technologies that are adaptive, flexible and intelligent, to enable users to participate fully in their daily lives.”

Their work ranges from a powered anti-collision wheelchair and a robotic arm that uses artificial intelligence to help stroke patients regain upper body strength, to a variety of projects focusing on intelligent environments.

One of Dr. Mihailidis’ most exciting projects is a fall detection device designed to “allow older adults to remain in their homes independently and more safely for as long as possible, and to relieve the stress on family caregivers and friends. Falls are the most common cause of injury among older people.

One-third of older adults fall every year and about 25% die from complications of their fall.”

Called ‘The Helper,’ the system— which is in the final development stages and awaiting an industrial partner to commercialize and market it at what will be an affordable price—is among a range of intelligent technologies he is

working on that uses computervision and voice-recognition software and can be integrated into a home network. The network would also include a smoke detector, burglar alarm, nutritional detection system and devices that prompt or coach users through activities from hand washing and getting dressed to taking medication and preparing meals.

An intelligent home environment would allow the occupant to use as little or as much of the home’s capability as needed. As the occupant ages, the home adjusts to meet their changing needs in order to support independent living for as long as possible.

The next challenge for Dr. Mihailidis and his team: how to move from standalone systems that need to be installed in a home to a fully integrated intelligent home environment. “Could we make the house itself the technology? Could all these capabilities be incorporated into the building materials themselves?”

Dr. Mihailidis informally refers to this concept as “brick computing” because every brick or other building materials, such as flooring or wallboard, could include “the computer and networking capabilities needed for an intelligent environment.

“I’m hoping to use this research

chair to explore the integrated concept and other ideas about what a smart home would look like,” he says. “The idea is that no matter what you are doing, the home recognizes your intent. No matter what your abilities and preferences, it provides a system to meet your needs—whether it’s prompting, doing tasks or reminding you where your keys are. These systems would apply to anyone—with or without a disability.”

Honouring Barbara Stymiest

The Barbara G. Stymiest Chair in Rehabilitation Technology Research was made possible by donors to Everything Humanly Possible: The Campaign for Toronto Rehab in honour of the outstanding Campaign Chair—Barbara Stymiest, Group Head, Strategy, Treasury & Corporate Services at RBC.

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news Minister of Health helps to “top off” new wing On April 21, the Hon. Deb Matthews, Minister of Health and Long-Term Care, joined hospital officials, employees and special guests to celebrate the “topping-off” of the new patient care and research wing at Toronto Rehab’s University Centre. A “topping off” ceremony is a tradition on building sites, signifying that the highest point of a building Getting ready to “top off” the new wing: Mark Rochon, President & CEO, Toronto Rehab (left); has been reached. the Hon. Deb Matthews, Ontario Minister of “This is where research and Health and Long-Term Care; and David Bragg, patient care will be married,” Chair, Board of Directors, Toronto Rehab. said Minister Matthews.

“Miracles will happen here. Congratulations to all of you…When complete, this redeveloped hospital will offer patients improved access to enhanced rehabilitative care”.

Toronto Rehab receives full Accreditation status

“Toronto Rehab is a high-performing, dynamic, engaged organization which is focused on providing exemplary quality care to meet the needs of the patients and families it serves,” according to Accreditation Canada surveyors who spent four days on site in May evaluating hospital services against national quality standards.

Toronto Rehab has just learned that it received full Accreditation status from Accreditation Canada for the fourth consecutive time during the past decade. Only 10% of Canadian hospitals are awarded this level of Accreditation. Toronto Rehab was also recognized for seven leading practices that have a positive impact either on services or outcomes for patients and families or on the health system.

Toronto Rehab’s stroke rehabilitation service, which participated in a separate, rigorous review by Accreditation Canada, is one of the first programs in the country to earn a Distinction in Stroke Services award from Accreditation Canada. The award was announced at the National Stroke Strategy Congress earlier in June.

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Big ideas and smart solutions Toronto Rehab’s new +9 Report on Rehabilitation Research spotlights some of our best ideas to help people stay independent as they age.

These approaches can also assist individuals of all ages who are living with disabling injury and illness. On the pages of +9, you’ll find out about our innovative solutions to speed and enhance recovery, keep people out of hospital, support people in their own homes, and assist professional and family caregivers. To read +9, visit www.torontorehab.com or contact Lois Ward at 416-597-3422, ext. 7600 (ward.lois@torontorehab. on.ca) for a copy of the report.

Introducing SpinalCordConnections.ca Toronto Rehabilitation Institute and Canadian Paraplegic Association Ontario (CPA Ontario) have created Spinal Cord Connections, an innovative new electronic resource centre for individuals with spinal cord injury, their families and communitybased service providers across the country.

Launched in May, www.SpinalCordConnections.ca provides online access to current, evidence-based information about spinal cord injury, its treatment and care, as well as information about support services and events. A natural extension of CPA Ontario and Toronto Rehab’s resource centre located at Lyndhurst Centre, Spinal Cord Connections is a new and creative approach to enhancing the health and quality of life among individuals with spinal cord injury. By creating an online community that stretches across the country and beyond, the partner organizations hope to facilitate information sharing and peer support among individuals with spinal cord injury, and to help them in managing their own care and maintaining their good health.

SoleSensor improves balance, prevents falls Toronto Rehab scientists have developed an insole that is keeping older people on their feet and out of hospital. A simple footwear insole called SoleSensor ™, developed by Stephen Perry, Toronto Rehab adjunct scientist and associate professor of kinesiology and physical education at Wilfrid Laurier University, has been proven to improve balance and prevent falls.

SoleSensor enhances balance by heightening foot-sole sensation. It has a raised ridge that surrounds the perimeter of the foot, stopping just short of the large toe. This ridge is designed to enhance the sole’s sensory perception by stimulating tiny sensors located in the outer edges of the sole.

SoleSensor is available at pharmacies across Canada or online at www.ajhartgroup.com

Living With/Living Well Toronto Rehab’s free public education series, Living With/Living Well, will be back for another season starting in September. The upcoming monthly sessions explore topics such as battling fibromyalgia, communicating after stroke, aging without isolation, and more.

Educational material to complement each session is posted online.

For a list of upcoming events and an archive of educational materials from past events, visit www.torontorehab.com/ livingwithlivingwell

On Track to Cardiac Recovery Toronto Rehab Foundation proudly hosted the seventh annual On Track to Cardiac Recovery fundraising walk in February. Over 375 participants raised $100,000 in support of the hospital’s cardiac rehab and secondary prevention program. The Foundation is grateful to our presenting sponsor, The Dominion, as well as other event sponsors Deloitte., James B. Archer-Shee & Mary C. Matthews, Subway, Thomas, Large and Singer Inc., Canadian ICEBERG Vodka Corp, Harlequin, Investors Group and Running Free.

Kudos to Toronto Rehab staff Nazlin Hirji, Director of Nursing, and Nancy Boaro, Advanced Practice Leader in the neuro rehabilitation program, received awards of excellence in nursing administration and nursing practice, respectively, from the Toronto-based chapter of Sigma Theta Tau International, a global community of nurse leaders.

Lynne Sinclair, Toronto Rehab’s Director of Education, has also taken on the role of Associate Director, Centre for Interprofessional Education, University of Toronto.

Toronto Rehab researchers have been awarded $4.6 million by the Ontario Ministry of Research and Innovation to develop innovative assistive devices and advanced technologies to help people care for someone at home. Toronto Rehab engineers, computer scientists, designers and clinicians will collaborate with industry leaders to design, develop and bring new products to market quickly and at a reasonable price to consumers.

Marie Cassidy, RPN and Veleta Douglas, RPN, both longterm Toronto Rehab employees and members of the hospital’s musculoskeletal rehabilitation program, received honourable mentions in the Toronto Star Nightingale Awards for excellence in the field of nursing.

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Hand hygiene system Can it curb infections and save lives?

In 2011, Toronto Rehab will conduct a year-long clinical trial on a high-tech hand hygiene system to determine if it can help reduce the number of infections patients acquire in hospital and potentially save thousands of lives each year.

The Canadian Institutes of Health Research has awarded Dr. Geoff Fernie, Vice President of Research at Toronto Rehab, and his team a $371,652 grant to test an intelligent hand hygiene monitoring and prompting system on a 50-bed nursing unit at the hospital’s E.W. Bickle Centre for Complex Continuing Care.

Each year in Canada, approximately 10% of patients—or 220,000 people—acquire infections while hospitalized, and roughly half of these infections occur because health care professionals do not wash their hands.

Of those patients infected, as many as 8,000 die each year—making hospitalacquired infection the fourth leading cause of death.

“Conventional hand hygiene programs increase hand washing for a while but eventually levels of hand hygiene drop off again,” says Dr. Fernie.

“We need a sustainable solution to this challenging problem.”

It is important for the public to understand that busy clinicians who follow hand hygiene rules might be required to wash their hands up to 150 times in an eight-hour shift, explains Dr. Fernie. “The issue is a lot more complicated than people may realize. What health care professionals need is a reminder that doesn’t interrupt their ability to get things done.”

Toronto Rehab’s solution is a sophisticated electronic system designed by Dr. Alexander Levchenko to monitor and modify caregivers’ hand hygiene behaviour. At the heart of the system is a ‘smart ID badge’ with an infrared sensor which is clipped to the caregiver’s pocket or worn on a lanyard around the neck. The sensor interacts with tiny infrared emitters mounted on the ceiling in the zones where hand hygiene monitoring is critical—such as

patient beds, room entrances, dirty utility rooms and other areas where there is a high risk of infection.

When a health care worker enters or leaves one of these zones, and the person has forgotten to perform hand hygiene, the device vibrates or produces an audible prompt. If hand hygiene rules are followed, the device displays a green light.

The same device also maintains detailed data on hand hygiene habits. This data is downloaded, analyzed, and hand hygiene performance reports are generated so caregivers can see where there is room for improvement.

Recent pilot tests conducted in four occupied patient rooms at the Bickle Centre produced findings that were “very exciting,” according to Dr. Levchenko.

“Our initial results actually exceeded my expectations. The clinical trial will enable us to see whether the improvement that we have observed in our pilot tests is sustainable.”

Dr. Veronique Boscart, a nurseresearcher on the team, says the nurses who have tested the system are enthusiastic. “The nurses really see it as helping them to practice nursing in a better way. This project is an ideal example of something that can change practice and improve the situation for patients. The nurses value having the opportunity for input on the development of the system rather than just having to implement something that is delivered to the unit.

“As a nurse, I don’t need something that tells me afterward what I did wrong. I need a reminder while I’m doing it. It’s very timely and it’s very convenient,” adds Dr. Boscart. She says the nurses particularly like the wearable alcohol gel dispenser (gelFAST, which was also developed in collaboration with Toronto Rehab) because “it is geared toward the nurse who is moving from one place to another.”

Dr. Matthew Muller, an infectious diseases physician at St. Michael’s Hospital and a member of the project team, believes the hand hygiene monitoring and prompting system is “a very logical method to quickly

“What health care professionals need is a reminder that doesn’t interrupt their ability to get things done.”

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Ceiling-mounted ‘emitters’ provide information, such as location and a patient’s contagion level, to a portable electronic device.

This electronic device vibrates or beeps if the user forgets to wash his or her hands.

Dr. Veronique Boscart

A wearable alcohol gel dispenser.

When gel is used, a signal goes to the electronic device, indicating that hand washing has occurred.

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boost and sustain hand hygiene numbers in a way that hasn’t been achieved previously.”

He likens hand hygiene to wearing a seatbelt or bike helmet. “Once you do it for a long enough period of time that it becomes a habit, you don’t feel comfortable if your seatbelt or bike helmet isn’t on.

If we can monitor people continuously for a couple of months and really get them up to 100% hand hygiene compliance, what I suspect is that they are going to start feeling like their hands are unclean even if the monitoring system is disconnected.”

The research team is also developing a way for the system to use artificial intelligence to analyze caregivers’ movements and determine exactly when they need to wash their hands.

“The idea is that the badge you wear would make intelligent decisions that will provide a level of reminder proportional to the risk,” explains Dr. Fernie.

“If you intend to just say good morning and not touch the patient, then clearly that doesn’t require the same level of attention as if you’ve just left a room after providing close care to someone who has a serious infection.”

While there is considerable interest in getting the hand hygiene system on the market, the clinical trial is an essential step to determine how well the system works—technically, in terms of user feedback and lasting changes in hand hygiene compliance. “We want to make sure that we really do understand the problem and we have a solution that is practical and not gimmicky—something that will really work,” says Dr. Fernie.

If the clinical trial succeeds, he says the long-term goal is to use this system to help reduce deaths in North America from hospital-acquired infection by 25,000 a year.

Introducing HandyAudit

Toronto Rehab scientists have developed an easy-to-use electronic tool that helps hand hygiene auditors efficiently monitor and report hand hygiene compliance rates, which will ultimately make patients and hospitals even safer.

HandyAudit™ is designed to improve on the current paper-based system that requires auditors to simultaneously monitor and record the hand washing habits of several people at once. The system consists of a personal digital assistant (PDA) and a web-based application.

While observing the activities of several health care providers at a time,

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auditors use touch screen technology to simply input actions into the PDA. Auditors record typical activities such as: entering the patient’s room, touching the patient, cleaning open wounds, using an alcohol gel hand sanitizer or leaving the patient’s room.

Once data is downloaded from the PDA to the secure website, the HandyAudit software analyzes the actions and then calculates hand hygiene compliance rates.

“With the paper form, you’re asked to observe several people at once while interpreting and recording whether or not a person has washed their hands before and after touching a patient or performing a medical procedure,” says Dr. Matthew Muller, an infectious diseases physician at St. Michael’s Hospital who worked on the HandyAudit team. “It’s more complex than it appears. It’s also well known that mistakes occur when the forms are handed over to someone else to enter the data into the computer.”

HandyAudit eases the process of collecting, recording, analyzing and reporting hand hygiene compliance practices by taking personal judgment out of determining hand hygiene compliance. The device could also save hospitals money and time by

simplifying auditor training and eliminating the need to transcribe information from paper to computer.

Ontario hospitals—and increasingly other health care jurisdictions across the country and around the world—are required to publicly report their annual hand hygiene compliance rates. One of the benefits of HandyAudit is that “if the rules change, we don’t have to go back and re-observe anything,” explains Michael Tsang, a doctoral candidate in computer science at the University of Toronto and a member of the research team. “We can just run it through the computer according to the new rules and it will re-analyze the data.”

Toronto Rehab iDAPT research associate César Marquez Chin, whose work focused on customized programming of the handheld PDA, believes that HandyAudit and the intelligent hand hygiene monitoring and prompting system will generate complementary information. “Both systems generate detailed data that will make it possible to conduct very deep, very interesting research on hand hygiene that hopefully will have a real impact on infection rates.”

For more information on HandyAudit, visit www.handyaudit.com

Lessons of a cheese sandwich Leah Good and her grandfather Harvey Joseph share a cheese sandwich.

When nine-year-old Leah Good wanted to teach her grade 4 keep me motivated,” says Harvey, a lawyer of 40 years and a classmates about the challenges of living with a disability, she partner in the Toronto firm of Joseph & O’Donoghue, LLP. had them make cheese sandwiches—“Toronto Rehab style.”

The grandchildren were all part of a family campaign to Leah instructed each student to hold their dominant “Get Papa Moving,” explains Harvey’s daughter and Leah’s arm—“the one you write with”—behind their back and mother, Jennifer Joseph. to make the sandwich with the other arm. The children Harvey is proud to report that he kept a promise to his struggled with their assignment—awkwardly trying to spread grandchildren to take the extended family of 16 people to margarine on the bread, lay in the cheese slice, cut the Florida’s Disney World as soon as he was well enough. “It sandwich in half with a knife and wrap it in a plastic bag. took two years but we did it!”

“Everyone found it very difficult,” says Leah. “They all had “Dad got on and off of rides and boats with the kids,” adds to have some help.”

Jennifer. “He did everything he wanted to do. The hard work The exercise was Leah’s attempt to show how paralysis pays off.” her grandfather experienced on one side of his body from Harvey sustained a stroke on March 11, 2008. “Toronto a stroke had affected his Western Hospital saved my life but independence and made even the Toronto Rehab gave my life back “The project was fun and I simplest task very difficult. me. They were fantastic—just think it taught everybody about to Leah’s demonstration was the right mix of ‘we’re not going to part of Project Give Back at her our story and Toronto Rehab.” do it for you, you’re going to have school. After spending time at to do it yourself,’ and kindness and Toronto Rehab with her grandfather, Harvey Joseph, during humanity. They just worked their magic and it’s been terrific.” his stroke rehabilitation, Leah decided to focus her project on Harvey and Marsha, his wife of 47 years, were so the work of the hospital. “The project was fun and I think it impressed with the inpatient and outpatient stroke taught everybody about our story and Toronto Rehab.” rehabilitation service that they made a donation to the Over a six-week period in the spring of 2008, Leah had Toronto Rehab Foundation. The donation will be recognized watched her grandfather progress from being unable to sit with the naming of a patient room at the hospital’s University independently to walking out of Toronto Rehab using a cane.

Centre, which is under redevelopment. “I made the gift “I didn’t think he’d ever walk, or shave alone or work again. because I owe a tremendous amount to Toronto Rehab. It’s But I learned that things do get better with a lot of hard nice that it’s a patient room we are funding because that’s work—and that he’s the same person he was before. I’m very where my heart is—with the patients.” proud of my grandfather,” says Leah.

A quick glance in Harvey’s direction tells an onlooker Please give today to help someone you love get their life back. that the feeling is mutual. “Leah and my other seven Contact the Toronto Rehab Foundation at 416-597-3040 or grandchildren are my cheering section. They have helped to visit www.torontorehabfoundation.com TORONTO

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Post script Julia Brimo has her eye on the finish line—and if the 34-year-old jockey has her way, she’ll

be back racing thoroughbred horses as early as this autumn. The Mississauga native—and winner of Canada’s Sovereign Award as top apprentice jockey after riding 75 winners in 2003—sustained a broken neck and spinal cord injury in a fall during a race on October 30, 2009, at the Keeneland racetrack in Lexington, Kentucky. She was listed in critical condition in hospital, where the staff prepared her family for a possible outcome of quadriplegia. Following surgery, Julia returned home to complete Toronto Rehab’s spinal cord rehabilitation program at the hospital’s Lyndhurst Centre. She was fortunate that mobility in her legs recovered quickly which allowed a focus on strengthening and on recovery of her arms, particularly her right arm which did not have full range of motion. “They did a great job at Lyndhurst and laid a solid foundation for my recovery,” says Julia. She gives special credit to occupational therapist Sylvia Haycock, who worked with Julia throughout her two-month inpatient stay. “Sylvia has a huge heart and is so dedicated to getting people well. We worked great together; she understood my goals and my drive to achieve them.” Julia is pictured above in a thoughtful portrait and riding prior to her accident. In April, Julia beamed for the camera as she was about to get on a pony for her first ride since her spinal cord injury.

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