In Touch newsletter: April 2016

INTOUCH APRIL 2016

Violeta Palmares, a nurse in the NICU, helps a mother care for her newborn. (Photo by Katie Cooper, Medical Media Centre)

NICU initiative gives parents opportunity to play larger role in newborns’ care

By Rebecca Goss

Parents will be able to play a much larger role in their child’s care in the Neonatal Intensive Care Unit starting this spring.

The NICU will pilot a family integrated care project, allowing parents to participate in rounds, contribute to the care plan, assist in feedings, change diapers and write any developments, improvements or concerns in a parent version of their baby’s chart.

Increased participation in these activities allows for better communication between parents Printed on 100 per cent recycled paper

and health-care providers and allows parents the opportunity to start making decisions sooner in their newborn’s life, said Dr. Ethel Ying, a pediatrician in the NICU.

care breastfeed more frequently and gain weight faster. The stress levels also decrease as parents become more confident around their baby, said Dr. Ying.

Nurses will be instrumental initially to coach, teach and support parents in the care of the baby, gradually weaning their “hands on” involvement as parents become comfortable.

“Everyone in the NICU benefits from this program,” said Dr. Ying.

At other hospitals, this program has shown a decrease in length of stay for the newborns and in the incidence of hospital-acquired infection. As well, infants participating in family integrated

“The babies are healthier and leave sooner, the parents are more comfortable with their child and nurses get to take on a facilitator role to teach the parents.”

– Dr. Ethel Ying a NICU pediatrician Continued on page 2 APRIL 2016 | IN TOUCH | 1

OPEN MIKE with Doug Sinclair,

Executive Vice-President and Chief Medical Officer

Keep me safe We are going to help our staff understand how they can better partner with patients and families to reduce the risk of falls and we will put supports in place to ensure they don’t fall and hurt themselves in our care.

This month we are launching our 2016-17 Quality Improvement Plan. Or, as I like to think of it, our roadmap for improving quality and safety at St. Michael’s Hospital.

This blueprint required much effort from our Quality and Performance team, and I’d like to thank everyone for all of their hard work.

I would like to also thank our patients, families and caregivers. They, too, played an invaluable role in shaping our direction for the upcoming year.

Our areas of focus and our priorities for 2016-17 were designed based on what we heard from those for whom we care. We reached out to patients, their caregivers and family members through our advisory councils, surveys and a data review based on how they told us we can improve.

are important to them. We will continue to improve our patients’ satisfaction with their discharge experience and strive to reduce the amount of time admitted patients spend in the Emergency Department.

St. Michael’s has an excellent track record in managing and preventing hospitalacquired infections. But there is no limit to better. Hand cleaning continues to be a top priority. We will measure our progress through how our staff are doing in washing their hands before they come to patients’ bedsides.

We have been focusing on creating new ways to capture patients’ medication history and to ensure we share this information clearly with the broader health-care team. We will continue that work. We are designing a new electronic tool to help our doctors, nurses and pharmacists record what patients tell us is their medication list, allowing others on the team to update it consistently.

Keep me involved We recognize our patients come to us with a variety of needs and diverse backgrounds. We continue to build our Patient and Family Advisory Councils to help patients and their caregivers set priorities and have input into areas that

Make my transition from hospital seamless We are committed to ensuring patients feel ready when it’s time to leave. We will continue to improve our patients’ satisfaction with their discharge experience and strive to reduce the amount of time admitted patients spend in the Emergency Department. We also want to reduce the number of times they need to come back to the hospital, particularly for patients with chronic obstructive pulmonary disease and congestive heart failure.

Check out our plan, including a video and a one-pager for patients, families and caregivers at stmichaelshopsital.com/ quality.

NICU story continued from page 1

Moms and dads will also receive support and education from other parents as part of a biweekly parent education group.

Dr. Ying said this kind of networking allows parents to share experiences and advice.

“It’s great when parents are able to meet and bond with other parents in the NICU,” said Dr. Ying. “They know what each other are experiencing and can support each other.”

APRIL 2016 | IN TOUCH | 2

Mary Murphy, clinical leader manager for Obstetrics and Gynecology and the NICU, said this program fits in nicely with the NICU’s baby cuddling program, where carefully selected volunteers cuddle infants when their parents can’t be present.

“We’re taking patient and family engagement one step further and actually embedding parents in their newborns’ care,” said Murphy.

Follow St. Michael’s on Twitter: @StMikesHospital

Working with northern Ontario communities to improve concussion care

By Rebecca Goss

Physicians and nurses from St. Michael’s Hospital have launched an initiative to help improve concussion care in sports clinics, hospitals and health-care facilities in northern Ontario, where patients may have to travel up to three days to reach specialized care.

At the same time, hospital researchers are working with First Nations groups to study concussion trends in northern Ontario Aboriginal communities.

Dr. Donna Ouchterlony, head of the Head Injury Clinic, and Dr. Andrew Baker, head of critical care, are encouraging northern health regions to adopt the model of St. Michael’s Urgent Care Concussion Clinic to make care more accessible and efficient.

The Urgent Care Clinic bridges the gap between when a patient with a concussion visits an emergency department and, for those who need it, to see a specialist – which can take weeks.

Patients diagnosed with a concussion and discharged from the ED go home with an information booklet on their condition.

A clinical nurse specialist follows up with a phone call within a few days, completes a concussion questionnaire with the patient and, based on the score the patient receives, recommends the appropriate level of care.

Dr. Ouchterlony said she planned to create video seminars for northern community health centres to help teach and improve concussion care in northern communities, including Aboriginal communities. She said they were also planning to do telemedicine consults so that patients do not have to travel to receive care.

Dr. Cindy Hunt, a senior research associate with the Head Injury Clinic who has northern nursing experience, is leading a research project to study concussion trends in northern Ontario Aboriginal communities. She said that by making an effort to understand First Nations

Young hockey players in Serpent River hold hockey helmets purchased by the Head Injury Clinic with a grant from the Dr. Tom Pashby Sports Safety Fund, which is dedicated to the prevention of catastrophic injuries in sport and recreation. (Photo Courtesy of Serpent River)

knowledge and attitudes of concussions, the team hoped to develop a tailored approach to improve prevention, recognition and management of concussions with Ontario First Nations communities.

The study, the Fair and Safe Play project, is a collaboration between St. Michael’s, the Union of Ontario Indians and the Serpent River community, part of the Anishinabek Nation, two hours west of Sudbury.

Serpent River has a population of 1,200 and a vibrant hockey community. Its one outdoor rink sees parents, grandparents, elders and coaches gather to cheer on the child and youth hockey teams. Its love for hockey makes Serpent River an ideal community for the Fair and Safe Play project, as studies show one in 10 youth athletes will suffer a concussion while playing hockey in Canada, said Dr. Hunt.

The study was recently conducted at the Little Native Hockey League tournament, where 170 First Nations teams with players aged 4 to 18 participated in Mississauga, ON. Carolyn Bennett, the federal minister of indigenous and aboriginal affairs, attended and took the concussion survey.

“Concussions are a huge and widely discussed problem right now, ” Dr. Ouchtrerlony said.

“The latest number that the Ontario Neurotrauma Foundation is reporting 1,800 per 100,000 people receiving concussions per year, but I think it’s much more.”

St. Michael’s is an RNAO Best Practice Spotlight Organization

APRIL 2016 | IN TOUCH | 3

Cardiologists Drs. Chris Buller (left to right) and Neil Fam, and cardiovascular surgeon Dr. Mark Petersen said St. Michael’s, a Valve Center of Excellence, keeps trying to push the boundaries to provide patients with safer options for the treatment of valvular heart disease.

(Photo by Katie Cooper, Medical Media Centre)

St. Michael’s achieves Canadian first during transseptal heart surgery

By James Wysotski

St. Michael’s is the first hospital in Canada to have performed a novel catheter-based valve replacement technique that allows cardiac patients to go home the next day instead of staying in hospital for up to 10 days.

Valves created from animal tissue often begin to fail 10 to 15 years after surgery, either becoming leaky or narrowed.

Usually, patients needing a replacement of these “bioprosthetic” mitral valves have two options: they can undergo open-heart surgery again or a procedure known as a trans-apical mitral valve replacement where the physician inserts a catheter between the ribs to replace the mitral valve on the still-beating heart.

While both viable options, a much less invasive mitral valve-in-valve procedure has been performed by Dr. Neil Fam, an interventional cardiologist and medical director of the Cardiac Intensive Care Unit, Dr. Mark Peterson, a cardiovascular surgeon and co-director of the Transcatheter Aortic Valve Program, and APRIL 2016 | IN TOUCH | 4

Dr. Chris Buller, director of Interventional Cardiology. Dr. Fam said he hoped this would become the standard of care for the appropriate patient.

“No major arteries are cut into,” Dr. Fam said. “There’s no heart incision. There are no chest tubes. There’s none of that. It’s such a safe procedure.”

Last fall, Drs. Fam and Peterson treated a 72-year-old man with severe mitral regurgitation caused by a leaking bioprosthetic mitral valve replacement from 1998, that was allowing blood to flow backward toward the lungs. After entering a catheter through a vein in the man’s leg and going up into the right atrium of his heart, they went through an inner wall – the interatrial septum – into the left atrium, placing the catheter deep inside the heart and right above the failing valve.

By placing a new valve inside the old one, the patient was left with only a small puncture in his leg. The procedure took less than an hour and the patient went

home the next day. Dr. Fam said the man has been seen in follow-up appointments and is doing great. The physicians have since performed the procedure on a second patient.

While the method of entering the body through a leg vein has been used in other heart procedures for decades, none used the transseptal (across the septum) approach until now. In the near future, Dr. Fam said he hoped to improve upon a North American first performed here in May 2014 when the heart team did a transapical native mitral valve replacement.

Next up, he said he hoped to do the same replacement using the transseptal approach, refining a procedure performed just once in the world earlier this year.

“Eventually, we won’t be going through the apex of the heart so much, and certainly less open-heart,” said Dr. Fam. “Transseptal procedures will provide more options for patients and hopefully makes things a lot safer with faster recovery.”

Slawomir Zulawnik, an RN on the PCU, tidies toiletries in the unit’s new washroom. (Photo by Yuri Markarov, Medical Media Centre)

New donor-funded washroom in Palliative Care Unit adds comfort for visiting family and friends

By Rebecca Goss

The Palliative Care Unit feels a bit more like home for patients’ loved ones with the opening of a new visitors’ washroom, thanks to a donation by the family of a former patient, Melvin Gilbert.

“He was a generous and philanthropic person,” said Heather Stefani, Gilbert’s daughter. “We wanted to give back specifically to the PCU and wanted to find a way to help the families. It’s what my dad would have wanted.”

Melvin Gilbert died in 2013 after 10 days in the PCU. The PCU strives to manage patients’ symptoms, such as pain, nausea or difficulty breathing, and to ensure comfort when cure is no longer possible.

The unit is designed for the comfort of patients and their families and friends. It has a kitchen, dining and lounge area, laundry facilities and small private meeting rooms.

Visitors now can also make use of a large, renovated washroom, providing more comfort, tranquility and space.

“Having a family member in the PCU is intense and sad and scary,” said Stefani.

“Hopefully it brings some peace to those visiting their loved ones.”

The new washroom has soft yellow walls and shiny new fixtures. It’s furnished with wooden cabinets, a long counter and mirror, a new toilet and sink, all chosen by Gilbert’s family. Baskets on the counter hold a large stock of fresh linens, face washes, lotions, toothbrushes and toothpaste, arranged with care next to potted orchids.

“Having a nice, fully stocked washroom makes the unit feel more like home,” said Penny McCrimmon, an RN in the PCU.

“It’s important to make both the patients and their loved ones as comfortable as possible.”

– Penny McCrimmon, registered nurse in the Palliative Care Unit

Flexible visiting hours in the unit mean some visitors stay with their loved ones for days or weeks at a time. The new washroom gives visitors more space to refresh compared to the former visitors’ washroom, which was cramped, inaccessible and lacked the counter space for toiletries.

“The new washroom is a much-needed improvement, said McCrimmon. “A little bit of comfort means a lot in challenging times.”

APRIL 2016 | IN TOUCH | 5

Anaphylaxis training coming to simulation centre

By Rebecca Goss

Allergies are becoming more and more common, with as many as 600,000 Canadians thought to be at risk of anaphylaxis, a severe allergic reaction to food, drugs, insect venom or latex.

Yet medical students rarely – if ever – come across a patient having an anaphylactic reaction because most take place outside of a hospital and they last only a few minutes.

Proper training in how to treat anaphylaxis is vital at St. Michael’s, which has the largest combined adult and pediatric allergy and immunology residency program in Canada, in partnership with The Hospital for Sick Children. The hospital also has the largest adult cystic fibrosis program in North America and CF patients are more prone to adverse drug reactions than those without CF. Researchers at St Michael’s have developed a first-of-its-kind simulation for allergy and immunology residents to practice treating anaphylaxis.

Dr. Stephen Betschel, program director for clinical immunology and allergy, came up with the idea for the simulation and received $6,000 for the project from the Department of Medicine Innovation Fund.

Residents will do the simulation four times (twice a year) during their rotation at St. Michael’s.

The simulation involves the student identifying and treating an anaphylactic reaction in a mock-hospital setting in the Allan Waters Family Simulation Centre. Students will deal primarily with medication allergies during the simulation, since they are the most common cause of anaphylactic reactions

Dr. Christine Song, an allergy and immunology specialist, shows how to give a patient epinephrine in the Simulation Centre. (Photo by Yuri Markarov, Medical Media Centre)

in hospitals. Working together as a medical team, timeliness in diagnosis and providing proper treatment are some things educators will be watching closely.

The simulation relies heavily on peer feedback and debriefing afterward to retain more knowledge.

By analyzing and diagnosing an anaphylactic patient in the simulation, as opposed to simply treating the patient, students experience a much more accurate anaphylaxis situation, said Dr. Christine Song, an immunology and allergy specialist and lead educator on the project. Patients arrive at the hospital in various states of consciousness, so they may not be able to tell health-care workers about their allergies and may not be aware they have allergies.

“We were concerned there would be residents who go out and start practising without ever having hands-on experience dealing with an anaphylactic reaction,” said Dr. Song. “The repetition and practice is important for learners because the more times something is reinforced the more it becomes secondnature. For anaphylaxis, there are only seconds to minutes to react or your patient could die.”

The first simulation is scheduled for this summer with plans to expand the program pending more funding and interest. If the simulation is effective with allergy and immunology residents, Dr. Song and Dr. Betschel said they hoped to expand it to other students and staff.

LIST OF MOST COMMON ANAPHYLAXIS TRIGGERS: peanuts and tree nuts, fish and shellfish, eggs, dairy products, medications, insect bites and stings, latex APRIL 2016 | IN TOUCH | 6

St. Michael’s pediatrician Dr. Elizabeth Young is now welcoming patients to the new Developmental Outreach Clinic at 410 Sherbourne.

(Photo by Yuri Markarov, Medical Media Centre)

Connected care: St. Michael’s launches new pediatric development clinic

By Kendra Stephenson

Filled with colourful blocks, a big red couch and toy trains, the large exam room at 410 Sherbourne looks like any pediatric room – but it’s special.

St. Michael’s Family Medicine and Pediatrics Departments launched the Developmental Outreach Clinic here in March, a joint initiative providing integrated care for children with developmental disorders in Toronto’s inner city community.

Dr. Elizabeth Young, a developmental pediatrician, sees patients referred directly from the Family Health or Pediatric teams to assess and diagnose developmental disorders such as autism. Dr. Young works with pediatricians Dr. Ripu Minhas and Dr. Joelene Huber to follow patient treatment alongside their family doctor, better supporting families and children.

“For these families, the first hurdle is often seeing a doctor for a diagnosis to then access the specialized services within

our health system,” said Dr. Young. “The second is navigating that system, which is extremely difficult and much harder for families new to Canada or with financial constraints.”

Children need a diagnosis to obtain future referrals, enhanced help in schools and admission to programs such as respite care or behavioural management.

However, Statistics Canada reports about 39 per cent of children with disabilities – which includes development disorders – experience long waiting periods to get a diagnosis. Additionally, 30 per cent have difficulty obtaining a referral or appointment with a specialist and 26 per cent couldn’t get a diagnosis locally.

“These families get overwhelmed and either try to contact everyone or end up seeing no one,” said Dr. Young. “I think parents might be more willing to come to us because we’re in their community, the referrals are internal and their family

doctor is a part of the conversation.”

Once diagnosed, the clinic specialists will evaluate each child and treat him or her accordingly, with the goal of transitioning care back to the family doctor. Within this connected model, the team can develop a unique plan for ongoing care, managing medications and sharing test results from early years to adulthood.

Currently accepting internal referrals from the St. Michael’s team, Dr. Young hopes the model can be opened to other facilities and expanded into other areas of care, such as mental health.

“The clinic will continue to grow with the children it’s helping,” said Dr. Young. “I’m learning new areas of need from these patients every day; challenges I haven’t thought of before. With our expertise and the family doctor’s help, we can ensure this vulnerable population doesn’t fall through the cracks.”

APRIL 2016 | IN TOUCH | 7

Q&A

SHERRA SOLWAY

Sherra Solway prepares staff on 4 Bond for accreditation by playing “reverse Jeopardy:” a game that tests staff knowledge of St. Michael’s standards and practices. (Photo by Yuri Markarov, Medical Media Centre).

By Melissa Di Costanzo

Sherra Solway is trained as a physiotherapist and has a master’s degree in rehab science and a master’s of health science degree in health administration. She took on the position of quality lead for accreditation at St. Michael’s one year ago, just in time for the organization’s May on-site survey.

Q: What attracted you to this job?

I was intrigued when I saw the role posted as a full-time, permanent position. Typically, accreditation roles are contract, to prepare an organization for the once-every-four-years on-site survey. I learned St. Michael’s embraces the spirit of accreditation, which is that it is a quality improvement journey. I truly believe it should be something that is positive: we’re looking for opportunities to serve patients better.

Q: What kind of accreditation-related experience do you bring to the role?

I was a director of best practice, patient care projects and patient safety at the Toronto Rehabilitation Institute, where part of my portfolio was ensuring all required organizational practices are up-to-date and in place (ROPs are essential accreditation practices

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APRIL 2016

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that organizations must have in place to enhance patient safety and minimize risk). I’ve always been passionate about best practice and quality improvement, and that sparked an interest in accreditation and becoming a surveyor (senior health-care professionals from accredited organizations in a variety of health and social services sectors who conduct the on-site survey, assessing the quality of programs and services against the standards and sharing their expertise).

Q. What is the most rewarding part of your role?

Working with the accreditation team leads and staff, helping them with their improvement efforts, and providing them with the support they need to be ready for accreditation and to do their own roles. Working with the people who really want to make a difference and who really want to do a great job – that makes me feel like I’m making a contribution.

Q: What are your plans the week after accreditation?

Looking through travel catalogues and planning my summer retreat…and then preparing for the next round of accreditation (in 2020).