In Touch newsletter: February 2016

INTOUCH FEBRUARY 2016

Dr. Samuel Vaillancourt, an Emergency Department physician, led an initiative to help doctors reduce the number of CT scans when assessing patients with symptoms of pulmonary embolism. (Photo by Yuri Markarov, Medical Media Centre)

New initiative helps Emergency Department reduce number of CT scans

By Corinne Ton That

A new initiative at St. Michael’s Hospital is helping doctors and clinicians in the Emergency Department reduce the number of CT scans when assessing patients with symptoms of pulmonary embolism – a blood clot in the lung.

The initiative will help doctors and clinicians decide on the best test to use when assessing those patients, using new guidelines that helps them determine whether patients are at a low, moderate or high risk of having a pulmonary embolism.

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If a patient is deemed to be at a low or moderate risk, doctors can order a D-dimer blood test rather than a CT scan as an initial test. D-dimer tests are used to rule out the presence of blood clots by measuring a protein fragment in the blood, which is released when blood clots break up. If patients are at a high risk, they should undergo a CT scan immediately.

A pulmonary embolism can be lifethreatening and occurs when a blood clot in the leg breaks loose and travels to the lungs. Symptoms include shortness of breath, a rapid heartbeat and coughing up blood.

“There’s been a rapid increase in the use of CT scans for testing people with pulmonary embolism symptoms and this subjects patients to potentially harmful radiation,” said Dr. Samuel Vaillancourt, an ED doctor who led the initiative.

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FEBRUARY IS HEART MONTH For stories on our Heart and Vascular Program, please turn to pages 4 and 5 FEBRUARY 2016 | IN TOUCH | 1

OPEN MIKE with Cathy O’Neill,

Director, Quality and Performance

New year, new patient and family engagement opportunities walk around, and she was afraid to do that because she was worried the wound dressing would leak.”

I was thrilled my patient was happy, realizing that while I had helped her to Early into my nursing career, I cared for heal, I hadn’t taken the time to find out a woman with a large abdominal wound. what was truly important to her, and that was simply to go for a walk.

The first time I met her, the wound dressing was seeping.

That moment resonated with me. It’s vital to try to understand what’s important Communicating with this elderly to our patients. This, in addition to our woman was challenging due to a expert clinical care, will help them get language barrier. I knew she was upset. better, faster.

I assumed her distress was tied only to her physical discomfort. I was partially correct.

I rooted around for different wound care supplies, determined to secure the wound better and get my patient on a faster road to recovery.

I returned the following day, and was greeted by the woman’s daughter who said: “You’ve made my mom so happy.

The only thing she wanted to do was

A big part of my job involves supporting the organization in working with patients and families to improve their experience.

We know you’re eager to create meaningful connections with our patients. That’s why we’re partnering with our programs to help you, our staff, further your engagement work.

One way we’re going to do this is by taking a more comprehensive approach

to patient and family engagement. Our Patient Relations Office is evolving so we can better support programs in working with patients and families to navigate the system and challenging situations.

We’re purposefully creating outlets whereby patients and families can provide meaningful feedback. The first phase of this work is our St. Michael’s Patient and Family Advisory Councils, or PFACs. Through the PFACs, we will partner with Patient and Family Advisors who will share ideas and feedback on the patient and family experience at St. Michael’s, generating ideas on how to improve the overall experience. Through patient and family feedback, we’ll be able to identify further opportunities to improve our services.

It’s exciting work, and I invite you to embark on this journey with us. Let’s work together to enhance the patient and family experience. It will only continue to drive our pursuit of being better.

CT Scan story continued from page 1

“We’re trying to safely decrease the risk of radiation from CT scans by optimizing the use of the D-dimer test.”

The Department of Laboratory Medicine has devoted more resources to ensure D-dimer test results are available within an hour. If the test results are negative, patients don’t need to go onto further testing and imaging, said Dr. Kieran McIntyre, who also worked on the initiative.

“We’ve shown that if the D-dimer test is negative in patients with low to moderate risk of pulmonary embolism, then they don’t need to have further testing like CT scans– we know the D-dimer can safely rule out blood clots,” said Dr. McIntyre.

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Between two and three patients are assessed for pulmonary embolism in the ED at St. Michael’s every day and there is “good evidence that a lot of people in North America are getting avoidable CT scans,” said Dr. Vaillancourt.

“Research shows that up to 32 per cent of people at low or moderate risk of pulmonary embolism undergo potentially avoidable imaging,” he said.

The initiative, launched at St. Michael’s in September, is part of the Choosing Wisely campaign, which encourages doctors and patients to find ways to reduce the number of unnecessary tests, treatments and procedures.

Follow St. Michael’s on Twitter: @StMikesHospital

Mae Burke, clinical leader manager for the Therapeutic Endoscopy Unit, shows a copy of the unit’s Family Information Card. The small sheet of paper answers a number of patients’ and caregivers’ frequently asked questions, including the physician’s name, common procedures, as well as estimated wait times.

Family information cards answer vital patient questions

By Melissa Di Costanzo

As an endoscopy nurse for more than 25 years, Linda Pinches grew accustomed to hearing patients and family members ask the same questions: What is the name of my doctor? How long will surgery take?

How many hours will my loved one spend recuperating? She knows waiting and wondering how long a procedure will take places stress on patients and their families.

In an attempt to alleviate these fears and respond to these common queries, Pinches created the Therapeutic Endoscopy Unit 16 CC Family Information Card, which is handed out to all patients’ caregivers.

The small sheet of paper lists the physician’s name, common procedures, estimated wait times and recovery times.

A bronchoscopy (a procedure used to look inside the lungs’ airways) typically lasts an hour to an hour and a half, while a

colonoscopy (which allows physicians to look at the inner lining of the large intestine) runs anywhere from 45 minutes to an hour and a half.

The card, part of the unit’s goal to improve communication and an RNAO Best Practice Guideline initiative, reminds patients to have one relative or friend available to accompany the patient home after discharge. Coffee shops located in the hospital are also included and caregivers are encouraged to call the unit phone number for updates, to ensure they’re not left in the dark about their loved ones’ condition.

“It’s a very successful initiative as patients and their caregivers appreciate us keeping them in the loop, and providing them with as much information as possible before the procedure,” said Mae Burke, clinical leader manager for the Therapeutic Endoscopy Unit.

Patients from outside Toronto or the Greater Toronto Area, in particular, count the card as a reliable resource.

“They have a much better sense of how to plan their day, which can be challenging for people who live in northern Ontario, for example,” said Pinches.

The added bonus?

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

“Families love something they can put in their pocket” --Endoscopy nurse Linda Pinches

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Stocking the heart shelves smartly

By Leslie Shepherd

The Cardiac Catheterization Lab has borrowed a trick or two from the supermarket business in redesigning how it stocks its shelves.

Like milk cartons with best-before dates, supplies with expiration dates are now kept on the front of the shelf so they are picked up first. Some items even carry a bright lime green sticker saying “Use First” to reinforce the message.

Items that are not going to be reordered and can’t be returned are placed in an “orphanage box” for use if and where possible.

The moves are part of an effort to make sure the catheterization and electrophysiology lab have the right supplies on hand at the right time, from the right supplier with the right quantity and price.

Working with Procurement Services and Supply Chain, and with the active involvement of physicians, the lab looked at whether it could standardize supplies, remove products no longer being used, work out more realistic par levels (the minimum quantity of an item stocked) and reduce wastage.

As a result, it identified $400,000 in savings in 2015-16, making it one of the big success stories of the hospital’s Improvement Program.

Victoria Buczek, clinical leader manager for the Cath Lab, said the supply chain work began about 18 months ago, but gained momentum when the Heart and Vascular Program implemented recommendations from the Improvement Program and hired Valeria Afanasiev as the Cath Lab materials coordinator.

“Previously, our materials management practice was, if in doubt, just order,” Buczek said. “This practice resulted in too much product on hand.”

For example, the Cath Lab used to stock so many bare metal stents (a FEBRUARY 2016 | IN TOUCH | 4

Valeria Afanasiev, Cath Lab materials coordinator, left, and Victoria Buczek, CLM for the Cath Lab, examine a cardiac cath pack before stocking it in the supply room.

device used to keep coronary arteries open) that they took up two very long shelves in a crowded supply room. Yet bare metal stents are used in only 5 per cent of cases; the remaining 95 per cent use drug-eluting stents. The lab sent many of the bare metal stents back to the vendor and freed up space for more commonly used supplies.

The lab used to stock two different brands of balloons used in angioplasties.

Doctors preferred the less expensive one, but the more expensive one was stocked in the high-use procedure room, where doctors reached for what was handy. That’s been reversed.

Some of the other changes in the Cath Lab: • An upcoming barcode scanning system will allow staff to match what’s on the shelf with what’s in Lawson, the My Business electronic system, and more accurately track the cost of specific procedures.

• Supplies are restocked overnight, instead of between procedures • A new Supplier Representative Policy from the Procurement Services Department was developed to better manage vendor activities on site. For example, vendors have to make an appointment to come into the area and can check their inventory and replace stock only under supervision.

Peter Longo, director of strategic sourcing and logistics, said he hoped the supply chain changes tested in the Cath Lab can be a model for other areas in the hospital, starting with Perioperative Services.

Dr. Christopher Buller, an interventional cardiologist with St. Michael’s Hospital, holds an Impella heart pump—used to partially or fully take over the work of pumping blood in a patient’s heart. (Photo by Yuri Markarov, Medical Media Centre)

Small but mighty In the case of patients who need a heart transplant, the Impella can be a key tool to get the patients healthy enough to be safely transported to Toronto’s heart transplant centre at UHN.

By Geoff Koehler

It’s the width of a pipe cleaner and has a motor shorter than a pen cap.

With its diminutive proportions, the Impella is the world’s smallest heart pump—a minimally invasive, temporary life-support device.

“The miniature motor is a Jet Ski engine that can turn at several thousand r.p.m.to pump blood between ailing chambers of the heart— from the ventricle to the atrium—and then throughout the body,” said Dr. Christopher Buller, director of Cardiac Catheterization and Intervention for St. Michael’s Hospital.

Ventricular assist devices, such as the Impella, partially or completely replace a failing heart’s function of pumping blood through the heart and into the body. The Impella can do the

work for patients whose failing hearts are too weak for open-heart surgery. It also allows the clinical team to put the heart at rest during other complicated procedures.

“During a complicated angioplasty, we can use this mini pump to give the heart a break and do things that would not otherwise be survivable—such as blocking flow of a large blood vessel,” said Dr. Buller. “We can work more carefully, slowly and deliberately and maintain blood flow to the vital organs while the heart takes a breather.”

The Impella can be used for a few hours but not longer than a week or two.

Larger, battery-powered mechanical hearts, such as an LVAD (left ventricular assist device), can be used for several years to alleviate the heart’s workload— but installation of LVADs requires open-heart surgery and can take hours.

“We can install an Impella in 10 minutes,” said Dr. Buller. “From there, we can work more easily to stabilize the patient and get them healthy enough to recover on their own or stable enough for a long-term solution such as an LVAD or a heart transplant.”

The diminutive devices have been deployed five times at St. Michael’s since June. Dr. Buller is funded to use Impellas for 10 cases in 2015-2016.

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St. Michael’s working on test to diagnose Parkinson’s disease

Dr. David Munoz, head of the Department of Pathology, at his microscope. (Photo by Yuri Markarov, Medical Media Centre)

By Leslie Shepherd

Early diagnosis and treatment is critical for patients with Parkinson’s disease, because once the nervous system disorder starts destroying neurons they are gone forever.

The first is a biopsy of the submandibular gland, either of a pair of salivary glands found below the lower jaw. But this can be a difficult and invasive procedure, which neither physicians nor patients are keen to endure.

Yet a patient has only a 50 per cent chance of being correctly diagnosed with Parkinson’s disease on his or her first visit to a neurologist.

Dr. Munoz’s research project looks at two other options: testing for Parkinson’s during colonoscopies or through a skin biopsy, commonly performed by family physicians testing for skin conditions. By looking at tests conducted at the time of diagnosis, the researchers hope to compile evidence as to which is more accurate.

The head of the Division of Pathology at St. Michael’s Hospital is part of an international research project trying to determine which emerging medical test would most accurately diagnose Parkinson’s at an early stage. The work is funded in part by the Michael J. Fox Foundation for Parkinson’s Research, named for the Canadian actor who was diagnosed with young-onset Parkinson’s in 1991, and the Physicians’ Services Incorporated Foundation.

Dr. David Munoz, an adjunct scientist in the hospital’s Keenan Research Centre for Biomedical Science, said there are three possible approaches to diagnose Parkinson’s based on the presence of abnormal proteins found in areas outside of the brain.

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Dr. Munoz said the benefit of testing for Parkinson’s during a colonoscopy is that the test would just be part of the common test for colorectal cancer. Neurons are also present in the gastrointestinal tract, orchestrating the muscle contractions that move food through the tract.

He said one advantage of a skin or punch biopsy is that it is commonly performed under local anesthetic by family physicians in a doctor’s office or clinic for cancer or skin disorders. A device about the size of a pen nib removes a small piece of flesh.

“Eventually we hope to have a way of changing the diagnosis of Parkinson’s disease, which at this point is subject to a 50-per-cent error rate,” said Dr. Munoz. “Imagine trying to diagnose someone with diabetes without being able to measure their blood sugar.”

Making sense of mental health through mindfulness

By Corinne Ton That

For their first mindfulness exercise, participants of the Mindful Awareness Stabilization Training, or MAST program, practice eating a raisin.

Michelle Despres, a social worker at St. Michael’s Hospital and co-facilitator of the program, asks participants to focus on details of the dried fruit – what it feels and looks like. Then she asks them to put the raisin in their mouths and eat it, mindfully.

“Mindfulness helps people become more aware of their inner world, which can reduce stress that comes from thinking about the past or future,” said Despres. “There’s benefit to being in the present moment.”

Mindfulness meditation classes are offered to patients with chronic pain at St. Michael’s. This program, however, focuses on mindfulness therapies for patients with mental health issues.

Rachael Frankford, a social worker at St. Michael’s, founded the MAST program two years ago to teach people emotion regulation skills through mindfulness practice. That means learning to understand feelings, thoughts and sensations by focusing on the present moment, and learning to “sail as smoothly as possible regardless of the wind and waves,” said Frankford.

“This program helps people understand how to widen their window of tolerance – that zone where they’re able to thrive in daily life. So we give them meditations to do, which can be as short as three minutes, to help them build their tolerance.”

The program comprises of four two-hour sessions. Each one begins with a meditation exercise, followed by discussions of how people are implementing mindfulness practice at home, and lessons about topics such as self-care and emotion regulation.

Rachael Frankford leads a meditation session. Frankford founded the MAST program to teach people emotion regulation skills through mindfulness practice. (Photo by Katie Cooper, Medical Media Centre)

Participants range from 16 to 70 years old, and all have experienced mental health issues – from depression, anxiety and post-traumatic stress disorder, to psychosis.

“People learn that there are external factors and things going on in the brain that can bring about mental health issues.The insights that people have are really amazing once they learn how to understand their own mental health.”

--Rachael Frankford, a social worker at St. Michael’s Tara Johnson said she suffered from depression and post-traumatic stress disorder after growing up in an abusive family.

“When I turned 41, everything kind of exploded,” she said. “I had anxiety building up over the years and I even reached the point of giving up.”

Johnson started applying the lessons she learned in MAST in her personal life and saw a dramatic change. She learned to care for herself and identify the things she needs to feel comfortable and safe throughout the day.

“Once I began being mindful, I found my system started to relax,” said Johnson.

“Identifying our needs is a basic life skill, just like brushing our teeth or washing our hair. I can’t imagine how different my life would be if I had these skills since the time I was a little girl.”

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Suzanne Lu, a chiropodist in the Mobility Program , and Ann-Marie McLaren, a chiropodist in the Wound Care Department, perform the Ipswich Touch Test. (Photo by Yuri Markarov, Medical Media).

Testing new ways to screen for loss of sensation in diabetic patients

By Corinne Ton That A team of clinicians at St. Michael’s Hospital is testing a new way to assess patients for diabetic peripheral neuropathy, a loss of sensation in the feet that can result in an inability to feel pain.

Between 60 and 70 per cent of individuals with diabetes lose sensation in their feet, increasing their risk of foot ulcers, which can lead to infection and leg amputation.

The most common test for neuropathy is the monofilament test, which involves placing an instrument similar to a fishing line on areas of the foot, and asking if the patient feels sensation. But a much simpler test, called the Ipswich Touch Test, could be carried out at no cost, without the use of a special tool.

“This test could be used anywhere by anyone, meaning there would be no reason not to check patients with diabetes for

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neuropathy,” said Ann-Marie McLaren, a chiropodist in the Wound Care Department, who proposed and developed the study.

“We’re looking for a tool that can easily identify people with loss of sensation who are at risk for developing a foot ulcer.”

The Ipswich Touch Test, developed by Dr. Gerry Rayman in the U.K., involves examiners using their index finger to touch the tips of the patients’ first, third and fifth toes on both feet in a particular order.

Patients are asked to close their eyes and identify when the toe is touched.

“About 85 per cent of people who get their legs amputated had a diabetic ulcer, which they developed because they couldn’t feel their feet,” said Suzanne Lu, a chiropodist in the Mobility Program. “If we can put into practice a simple assessment tool, that means we could start catching people who have neuropathy earlier on, and prevent

FEBRUARY 2016

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these kinds of things from happening.”

The study team trained 16 clinicians to use both the Ipswich Touch Test and the monofilament test on eight diabetic patients at St. Michael’s. The team is trying to validate the Ipswich Touch Test to determine whether it could be used in various clinical settings among different health-care professionals including nurses, chiropodists, occupational therapists, physiotherapists, dieticians and physicians.

“We want to see if we can get agreement between the monofilament and Ipswich Touch tests, and see if the touch test works between different health-care practitioners, across different clinical areas,” said McLaren.

“With simple screening methods, early recognition of loss of sensation, education and appropriate referrals, we can prevent patients from developing foot complications and save limbs – that’s the ultimate goal.”