April 2011 Message from the President ....2 St. Mary’s Receives Award ........2 Hand Hygiene Improvement....3 Heart Month............................4 New Nuclear Imaging System..6 Adult Cystic Fibrosis Clinic ......7 Vitality ....................................8
Accreditation Results a ‘Huge Accomplishment’ St. Mary’s Expects to Achieve Full Accreditation by July St. Mary’s 2011 Accreditation survey is complete and the hospital has been awarded Accreditation with Condition of Report. This means that St. Mary’s has until July 17, 2011 to follow up on four opportunities for improvement identified in the report.
The team of surveyors provided significant positive feedback about St. Mary’s as an organization, and about our staff, physicians and volunteers. “Our surveyors commented time and time again how impressed they were with all those they met during the survey,” says President Don Shilton. “This perspective is repeated throughout our written report. I am proud that during their three-day visit, we were able to showcase the best that St. Mary’s has to offer,” he said. physicians
“All staff, physicians and volunteers should be proud of our accomplishment,” says Gillian Flynn Reuss, Accreditation Coordinator. “Their commitment and dedication enabled us to achieve an “All staff, outstanding result. We look forward to and volunteers providing the evidence necessary to achieve full be proud of Accreditation.”
should our accomplishment.”
Achieving Accreditation with only four areas to report on is a huge success that took a lot of hard work and dedication on behalf of our staff, physicians and volunteers.
Accreditation Canada says that 81 per cent of all organizations across Canada that are accredited through their organization receive an accreditation with condition award.
Some of the strengths acknowledged in the report include: • An openness and commitment within the organization at all levels to examine current processes and systems and make improvements.
The report by the surveyors noted that St. Mary’s complied with 98.5 per cent of the criteria reviewed. Considering the depth of the review, this is most commendable.
• The significant presence and role of our volunteers who greatly benefit our staff. • Our excellent relationships with our community partners as well as a high level of patient satisfaction. Here are the four areas that were identified as areas for improvement: • Identifying medical and surgical patients at risk of venous thromboembolism and providing appropriate thromboprophylaxis. • Identifying and implementing a list of abbreviations, symbols and dose designations that are not to be used in the organization. • Reconciling medications with the patient at referral or transfer, and communicating information about the patient’s medications to the service provider at referral or transfer to another setting, service, service provider or level of care, within or outside the organization. • Informing and educating patients and families in writing and verbally about their role in promoting safety.
Displaying the St. Mary’s Accreditation certificate are team members, from left, Bea Wilwerth, Gillian Flynn Reuss, Dianne Pletz and Patricia Wright. 1
For a more detailed report on the Accreditation survey, please visit the Intranet.
Outstanding Effort Shows Commitment to Patient Safety at St. Mary’s A Message from the President Dear Staff, Physicians and Volunteers:
The second area I wish to highlight is the enormous improvement in our hand hygiene compliance rates.
Every day the staff, physicians and volunteers of St. Mary’s make me proud. Two recent accomplishments deserve special recognition.
A year ago we identified this as a priority for improvement when our compliance rate was 56 per cent. We asked for a significant change in practice from our busy staff and physicians, and set an ambitious goal of 95 per cent compliance across all Four Moments of Hand Hygiene.
In February, surveyors from Accreditation Canada spent three days at St. Mary’s meeting many of you, reviewing our policies and procedures, and witnessing the caring, compassion and innovation that characterizes our hospital.
You responded with steady improvement. In several recent months you reached 100 per cent for Moments 2 and 3 and, in January, a 96 per cent combined average for Moments 1 and 4. This shows what is possible! As compliance rates have improved, there has been a corresponding decline in hospital acquired MRSA colonizations. From April to September of 2010, the hospital had 63 cases. In the second half of the year, when hand hygiene compliance rates reached and consistently exceeded 80 per cent, there were 48 cases of hospital acquired MRSA colonization; an immediate and significant benefit for our patients.
They were highly impressed. They praised the level of dedication, expertise and professionalism as well as a willingness to examine our current practices and find better and safer ways to do what we do. The surveyors produced a comprehensive report which highlighted our compliance with 98.5 per cent of the criteria reviewed, which is a huge accomplishment.
The 95 per cent target remains our firm goal. I urge you to redouble your efforts to meet it and beat it for the sake of our patients, as we strive to become the safest and most effective hospital in Canada.
My warmest thanks to all of you who work year-round to ensure that all practices are in place and functioning well to meet the highest standards and achieve full Accreditation. Our patients deserve no less.
Sincerely, Don Shilton, President
St. Mary’s Receives Chamber of Commerce Business Excellence Award St. Mary’s was one of 11 local organizations recognized in February with a Business Excellence Award at the Annual Greater KW Chamber of Commerce Gala. St. Mary’s received the Award for Excellence in Workplace Training. The nomination was put forward by a former staff member, and supporting documentation from our organization highlighted the various tools used to promote the skills and knowledge of our workforce, as well as the unique community education and outreach we do. This award wouldn’t be possible without the dedication and commitment of our clinical and corporate educators. “The theme was Roaring ‘20s and our St. Mary’s table was definitely one of the best dressed there. When they announced that St. Mary’s had won it was so incredible - spotlights on our table, champagne brought to us - a very proud moment indeed!” says Tammy Quigley, Director of Support Services. Dressed for the Roaring Twenties theme at the Gala are, from left, Giovanna Zinken, LeeAnne Kidd, Rachel Romany, Dianne Weir-Rowsell, Julie Emrich and Tammy Quigley. Photo by Adamski Photography
Congratulations to our great team of educators!
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Hand Hygiene Compliance Rates Show Dramatic Improvement Thanks to the diligence of staff and physicians, hand hygiene compliance rates have seen a dramatic rise in the past year.
Giovanna Zinken, Director of Infection Prevention and Control, says the campaign helped spread the word about the expectations and importance of hand hygiene to improve patient safety and reduce hospital acquired infections.
This improvement follows a hospital-wide campaign with a goal of 95 per cent compliance across all Four Moments of Hand Hygiene by March 31, 2011. “We set a very ambitious target that aligns with our goal to be the safest hospital in Canada,” says Sandra Hett, Vice President Patient Services and Chief Nursing Executive. In April of 2010, hospitals in Ontario were mandated for the first time to publicly report their compliance rates across two of the Four Moments of Hand Hygiene. St. Mary’s scored poorly. For Moment 1 – before contact with a patient and the patient’s environment – compliance was just 45.5 per cent. In the past year that rate increased monthly to a high of 93 per cent in January of 2011.
Hospital-wide averages for hand hygiene compliance reached, and were maintained, above 80 per cent from
For Moment 4 – after contact with a patient and the patient’s environment – the rate went from 66 per cent in March of 2010 to 92 per cent in March of 2011. The combined average for Moments 1 and 4 in January of 2011 reached a high of 96 per cent. However, the subsequent two months saw a slight dip, reinforcing the need for continued vigilance.
“We will continue our efforts until we reach our goal and surpass it.”
“We are going to continue our efforts until we reach our goal and surpass it,” Ms. Hett says. “We’re pleased with what we did achieve in our first year. It represents a significant change in practice.”
September onwards. During the first half of last year (April to September) the hospital had 63 cases of hospital acquired MRSA colonization. By comparison, during the second half of the year, there was a decrease to 48 cases of hospital acquired MRSA colonization.
Also, despite an increased number of patients in the month of January, coupled with a significant number of cases of influenza and the need to open overflow beds, “we had excellent hand hygiene during that month and we did not have an outbreak,” says Ms. Zinken. The introduction of daily staff huddles has given managers an opportunity for constant reinforcement of the importance of hand hygiene compliance at each of the Four Moments. For the coming year, the strategy will focus on continued audits, high visibility of infection control staff on inpatient units, and ongoing recognition, Ms. Zinken says.
Total number of observations Nov. 2010 to March, 2011 (Total compliance/total opportunity for compliance)
Moment 1
Moment 2
Moment 3
Moment 4
463/553
62/65
46/48
634/693
5 Consecutive months overall % compliance 84%
Shown at last June’s Hand Hygiene Awareness Day is staff member Rod Smith (left) and Dr. Bill Ciccotelli, Medical Director of Infectious Diseases/Medical Microbiology.
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95%
96%
92%
Heart Month Event Captures Why ‘Every Minute Counts’ Jay Gregg initially blamed the pain in his chest on the sushi and chili he ate that day. But when nausea, profuse sweating, and numbness in his arm and jaw followed, he called 911.
Dr. Brian McNamara, Chief of Cardiology, explained recent improvements, initiated by St. Mary’s, to speed access to treatment in Waterloo Region and Guelph, and in outlying areas as far away as Owen Sound and Lion’s Head.
In 6.5 minutes paramedics arrived at his Waterloo home, quickly performing an EKG and determining that he was having an ST Elevation Myocardial Infarction (STEMI) – a significant heart attack.
He credited Dr. Danielle Leddy and Nurse Clinician April McCullough for training paramedics with Waterloo Region EMS to interpret the 12-lead EKGs. They now perform and interpret the test on patients in the field to determine if they are having a STEMI. A step that involved transmitting results via BlackBerry to a cardiologist for interpretation has been omitted, saving further time.
Twenty-two minutes after that call, Mr. Gregg was wheeled past the Emergency Department at St. Mary’s to the Catheterization Lab where Dr. Brian McNamara and his team had assembled under the expanded external Code STEMI protocol. Mr. Gregg’s blocked arteries were opened with angioplasty and stents, restoring blood flow to his heart and limiting damage to the heart muscle. It happened well within the gold standard of 90 minutes “door to balloon” time.
“That is the level of confidence we have in the paramedics,” said Dr. McNamara. Roger Mayo, Operations Manager with Waterloo Region EMS, said that from October to December of 2010, door to balloon time for calls inside Waterloo Region ranged from 72 to 79 minutes, well within the gold standard.
“Twenty seven days later I feel better than I have felt in years,” a grateful Mr. Gregg told about 100 people on February 22 at a Heart Month event at St. Mary’s titled Every Minute Counts.
“We’re quite happy with the success to this point,” Mr. Mayo said.
The goal of the community event was to outline recent improvements in access to care for acute heart attacks at St. Mary’s and emphasize the importance of calling 911 over driving to hospital.
For patients who live outside the 90-minute window, access has also been improved by transferring them immediately to St. Mary’s after a clot-dissolving drug is administered in their local Emergency Department – rather than waiting there to see if the drug works. Once at St. Mary’s they will be considered for angioplasty within the next six hours in order to clear residual blockage.
“Every week many people drive themselves to the hospital because they don’t want to bother EMS,” said Nurse Practitioner Julie Kim. “The longer you wait at home the more damage is occurring to the heart muscle.” The most common symptom for both women and men is chest discomfort or pain. However, symptoms in women are often more vague than in men “Women don’t believe they’re having a heart attack so they’re more likely to delay treatment,” Ms. Kim added.
Dr. Stuart Smith, Chief of Cardiovascular Services, says the outlying hospitals, appreciate the improved access for their patients offered at St. Mary’s, since their communities often have no cardiologists. “They’re very grateful we’re here,” he said.
The evening also offered highly popular tours of the Cath Lab where participants heard paramedics explain their role, got a close-up look at stents and wires used in angioplasty and viewed an on-screen angiogram showing blockages.
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Up Close and Personal Cath Lab Tours a Hit “The tour through the Cath Lab was fantastic! It was extremely informative and very helpful to see the entire procedure on the screens.” Tour participant
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“My husband has two stents. It was interesting to see what they actually look like!” Tour participant
New Nuclear Imaging System is Safer and Faster St. Mary’s is one of the first hospitals in Ontario to offer heart patients the latest in nuclear imaging technology with a new machine that will improve safety, speed and comfort.
“With an elderly patient, who has trouble lying flat for long, we can do it in as little as three minutes with a full dose of the radioactive tracer, since the extra bit of radiation poses little threat,” explains Dr. Dubeau.
“Overall it improves the patient experience,” Christine Runnquist, Administrative Director of the Nuclear Medicine Program, says of the newly installed Cardiology Nuclear Imaging system.
“For someone in their thirties, who, because of their heart disease likely has many scans in their future, we would use a lower dose to expose them to less radiation and take 10 minutes to do the scan,” he says.
“For the patient it is more comfortable and a much shorter scan. We get an excellent image with a lower dose of radiation,” says Ms. Runnquist.
Ms. Runnquist says there are plans to initiate weight-based imaging to reduce radiation exposure, as was successfully trialed last fall with bone scans.
Cardiac nuclear medicine testing is commonly performed at St. Mary’s. A small amount of radioactive tracer is injected into the patient and the camera can detect gamma rays coming from the heart muscle, turning them into digital signals which indicate how blood is flowing in the heart, and how the heart muscle is contracting.
The new camera will operate eight hours a day, performing 2,000 to 2,500 scans a year. The existing camera will continue to be used for other types of scans, including bone, kidney or lung scans. The cost of the new system is $850,000. The hospital Foundation paid for the equipment through donations.
“On the current machine patients lay still with their arms above their head and the camera spins around them,” says Dr. Richard Dubeau, Chief of Nuclear Medicine. With this new machine, neither the patient nor the camera moves, allowing for a clearer image.
GE Healthcare began offering the system in 2009 and the Ottawa Heart Institute was the first in Canada and third in the world to purchase one. A team from St. Mary’s visited the Ottawa facility to view the machine and learn about its benefits.
“We often had to re-image the patient for another 20 to 25 minutes if they had trouble staying still,” he adds. “Now the test can be done in 10 minutes or less.”
“Since we are a well-respected cardiac centre, it is important that we offer the latest and most up-to-date technology for our patients,” says Dr. Dubeau.
He says once everyone is trained, the aim will be an average six minutes, but the timing is flexible.
Gina Du, Nuclear Medicine Technologist and Clinical Co-ordinator, demonstrates how patients are positioned on the new imaging system as Dr. Richard Dubeau, and Christine Runnquist look on. 6
Adult Cystic Fibrosis Clinic Transfers to St. Mary’s Move Will Improve Continuity of Care for Patients Beginning this month, St. Mary’s will welcome the first of 50 adult patients with Cystic Fibrosis whose outpatient care will be transferred from a long-established clinic for adult and pediatric CF patients at Grand River Hospital.
The number of adult patients has risen steadily due to population growth and increased longevity for patients. “Once a pediatric disease, CF is now definitely a part of adult respiratory medicine,” says Dr. Jackson.
The first full clinic for adults will be held on April 27th in the Robertson Centre for Airway Health at St. Mary’s. Clinics will be held twice a month. Pediatric patients will continue to be seen at Grand River. Since respiratory services for the region were consolidated at St. Mary’s several years ago, all adult CF patients needing admission have been cared for in the Chest Unit at St. Mary’s. Transferring the outpatient portion of their care to St. Mary’s will improve continuity of care, says Dr. Mary Jackson, Director of the Adult Cystic Fibrosis Clinic.
During their clinic visits at St. Mary’s, patients will see a familiar face in Lori Peterson, their long-time Nurse Co-ordinator at Grand River, as well as Dr. Jackson and Dr. Heather Racz, both respirologists, who, until now, travelled to Grand River for the adult clinics.
“Having separate adult and pediatric clinics is increasingly the model throughout Canada.”
“We are hoping to streamline patient visits, so patients can come in, see their team and then carry on with their lives,” says Leslie Slabon, Program Manager for the Chest Unit at St. Mary’s.
“This move is going to benefit patients and welcome them into a patient-centred adult environment.”
“One of the principal concepts of CF care is having a multidisciplinary team comprised of nurses, doctors, respiratory therapists, physiotherapists, dietitians, pharmacists and social workers,” says Dr. Jackson. “Having separate adult and pediatric clinics is increasingly the model throughout Canada.”
The voluntary transfer has been approved by the boards of both hospitals, the Waterloo Wellington Local Health Integration and Cystic Fibrosis Canada.
Dr. Jackson says when adult patients come to the clinic at St. Mary’s every three months, they will see team members who are committed to acquiring expertise in caring for adult CF patients.
Spring Regional Nursing Conference
Fun for the Family at Annual Bike and Hike
Plan to attend the Spring Regional Nursing Conference. The theme is Legalities, Documentation, Infection Control and Prevention
Join us for the Manulife Bike and Hike for Heart Waterloo Park on Sunday, June 5
When: Tuesday May 3rd, from 1630-2100 Where: The Waterloo Inn
The largest single community event that supports our Regional Cardiac Care Centre, this family friendly day focuses on support, community and a heart healthy lifestyle. Bring your bike, helmet and enthusiasm! Pedal your way to a good time in support of our hospital or enjoy an early morning jog or brisk walk down the walking trail.
Presentations include: • The Legal Importance of Documentation and Charting. Michele Warner (lawyer) • Social Implications of Antibiotic Resistant Organism (ARO) Colonization. Rena Burkholder RN
All hospital teams will have their entry fee paid for them.
• Clean Hands Save Lives – Be a Life Saver, Not a Time Saver! Margie Foster RN
Enjoy a delicious M&M Meat Shops lunch and dance to the live music! The kids can have their faces painted and shoot against the Kitchener Rangers!
• Nursing Documentation: Observations from the Complaints Bureau. Marilyn Irwin RN, MScN, BEd
Cheer on our “Hearts in Motion” team, made up of over 150 Cardiac Rehab patients and their families, and sponsored by ERB Transport. Call the Foundation at ext. 6539 for more information or to sign up!
Use this conference to help you meet your Quality Assurance requirements for the College of Nurses of Ontario! Cost: $50 - includes dinner For registration information contact Tara Willemsen at ext. 1823 7
Vitality - For a Happier, Healthier, More Active You! It’s Like Having a Personal Trainer Convenience, fun and an invigorating workout with a highlyskilled trainer, are what keep Terri Wunder and Rita Clark coming back to Vitality, the new staff health and wellness program at St. Mary’s. The co-workers from Occupational Health attend Body Flow classes three times a week. They acknowledge finding the time to work out can be tricky, but say this program makes it easier. “I knew I’d be more committed to a program at work rather than outside of the hospital,” says Ms. Wunder. “Here I feel more motivated to attend.” “If we are supporting it (Occupational Health), I feel like it can be a motivator for other people too,” added Ms Clark. Launched in February, Vitality offers staff, physicians and volunteers, and their families, easy access to a wide range of classes designed to help improve physical fitness. There are currently three diverse classes available, ranging from high intensity to lower intensity levels. One of the program’s greatest advantages is the trainer, Brian Romany. Mr. Romany has trained both amateur and professional local athletes and is focused on ensuring participants have an effective, safe, and fun workout. “Brian is in shape, knows what he’s doing, is a good motivator and a lot of fun. It’s almost as if you have a personal trainer,” says Ms. Clark.
Vitality participant Kahla Stern gives it her all as Trainer Brian Romany leads a smiling group.
LeeAnne Kidd, Vice President, Mission and Organizational Development, hopes to see Vitality grow to become a comprehensive, staff-driven wellness program. “Vitality provides a unique opportunity to staff, in that they are able to exercise on-site. Many staff have requested such a program over the years, especially since we had an empty, unused gym. Ms. Kidd says St. Mary’s is committed to continuing Vitality as long as there is sufficient interest and participation from staff. “We would love to expand it to include additional classes such as yoga and zumba, and maybe massage.” She encourages everyone to continue providing feedback and suggestions to improve Vitality. For more information, please contact: LeeAnne Kidd, 519-749-6497 or lkidd@smgh.ca
Vitality Basics Classes take place in the Health Hub (former Cardiac Rehab gym). For more information about the program, weekly schedules and pricing, check out the Intranet. Terri Wunder, left, and Rita Clark are enjoying Vitality classes.
Sign-up sheets are on the board outside the Health Hub. Sign up early. There must be a minimum of four participants to run the class.
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