In Touch newsletter: May 2017

INTOUCH MAY 2017

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Kayleigh Faulkner, a clinical nurse specialist for the Trauma and Neurosurgery Intensive Care Unit, and Orla Smith, part-time director of nursing/ clinical research, demonstrate “yoga at work”—one of the self-care techniques used in their project, ARISE, aimed at helping nurses address stress and build resilience. (Photo by Yuri Markarov, Medical Media Centre)

Building resiliency, in the workforce and on Facebook

By Geoff Koehler

Nurses experience stress in the workplace and in their everyday lives. These stressors can cause personal and professional challenges and negatively impact one’s health. While workplace stress cannot be eliminated, a team at St. Michael’s is taking steps to help nurses learn techniques to build resilience, mitigate stress and decrease fatigue.

“Nurses aren’t alone when it comes to experiencing stress, but the high-stakes environment and intense needs of patients in trauma and critical care can be especially challenging,” said Orla Smith, part-time director of nursing/clinical research at St. Michael’s. “We want to help.”

Smith is a critical care RN with a PhD

in Nursing and lead investigator on the project, called ARISE. The research team is comparing in-hospital workshops, online sessions and Facebook to see if they can enhance resiliency for up to 40 trauma and acute care nurses.

taught and practice self-care techniques, such as yoga, and shown how to use the senses and mindfulness for stress relief at home and at work. Participants also learn about creative and reflective reading and writing.

“Organizational employee health, wellness and assistance programs all provide this type of support; however, nurses are often unaware of all the options, and opportunities and access can be a challenge,” said Julie McShane, an RN and research coordinator who is part of the ARISE team.

To teach many of the self-care topics, ARISE capitalized on internal expertise at St. Michael’s. Kayleigh Faulkner, the Trauma and Neurosurgery Intensive Care Unit’s clinical nurse specialist, led “yoga at work” workshops. Cecilia Wan, an occupational therapist with St. Michael’s, and Dr. Jacquie Gardner-Nix, a chronic pain consultant for the hospital, designed and delivered the mindfulness components. Smith said there were several St. Michael’s staff members to

Through ARISE, nurses are presented with St. Michael’s hospital-based health and wellness resources, including its Employee and Family Assistance Program. They’re

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OPEN MIKE with Sonya Canzian

Executive Vice-President, Programs, Chief Nursing Executive, Chief Health Disciplines Executive degrees, PhDs and Canadian Nurses Association specialty certifications. Yes, this is nursing, and the calibre and scope of nursing practice at St. Michael’s are truly extraordinary.

Happy Nursing Week!

The Canadian Nurses Association 2017 National Nursing Week theme is #YESThisIsNursing.

In the outpatient and inpatient units, research, administration, education and in the community, St. Michael’s RNs and NPs work incredibly hard every day to deliver and enhance patient care, the nursing profession and the health system as a whole. Many of our nurses have advanced their own practices and pursued or completed their master’s

2017 marks St. Michael’s 125th anniversary. Nursing has been central to St. Michael’s story, and the hospital’s anniversary is a moment to reflect on our collective history and progress.

It’s also our five-year anniversary as a Registered Nurses’ Association of Ontario Best Practice Spotlight Organization. In 2016-17, 35 RN champions implemented 25 of the RNAO’s Best Practice Guideline initiatives. It’s been another great year in that respect.

Finally, I want to thank every one of our

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thank for their contributions to parts of the project.

“ARISE was built within St. Michael’s, with our people and for our nurses,” said Smith. “Because the project is tailored to our nurses it understands and reflects the context of our mission, values and patients. It was designed for the reality of the bedside nurse and their unique needs related to health and wellness.”

Participating nurses are also using a closed Facebook group to share ideas and provide peer support. McShane said feedback so far has been very positive. The team will assess the satisfaction of participants, monitoring how often the techniques are used and measuring the impact on nurses’ resilience.

1,887 RNs and 52 NPs for the work they do every day.

Thank you for advancing quality care, research and education at St. Michael’s.

Thank you for your patience and understanding as we get closer to moving into our new Peter Gilgan Patient Care Tower and expanded Slaight Family Emergency Department - and get closer to saying goodbye to construction-related disruptions!

Above all, thank you for always putting our patients and their families first.

I’ve celebrated Nursing Week along with you at St. Michael’s for many years, but this is my first one as your Chief Nursing Executive. I couldn’t be more proud to lead nursing at St. Michael’s.

ARISE provided nurses with a toolkit of techniques and approaches that can help promote well-being, including: o Yoga at work o Mindfulness o Expressing gratitude o Reflective writing o Reading for resilience o Simple techniques for sensory activation, including essential oils for topical and inhaled aromatherapy o Peer sharing and support (through Facebook) o Heightened awareness of hospital-based resources available through Corporate Health and other departments

“As a designated Best Practice Spotlight Organization, we incorporated recommendations from Registered Nurses’ Association of Ontario Best Practice Guidelines on healthy work environments into ARISE’s design,” said Ashley Skiffington, a core member of the ARISE project team and the hospital’s BPSO Designation and Sustainability lead. “Our nurses do so much to help our patients and families and our hope is that ARISE will help boost workplace health and safety and enhance individual well-being.”

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Follow St. Michael’s on Twitter: @StMikesHospital

MAY IS CYSTIC FIBROSIS AWARENESS MONTH

As RNAO best-practice-guideline champions, Grace Appiah-Kubi and Jessie Chiu had some protected time to work on their project, with the support of mentors in Professional Practice as well as Respirology. (Photo by Yuri Markarov, Medical Media Centre)

Plan early, talk often: normalizing end-of-life planning in the cystic fibrosis clinic

By Emily Holton

A nurse-led initiative in the cystic fibrosis clinic is making it easier to broach a difficult subject: planning for end of life.

“These conversations can be tough,” said RN Grace Appiah-Kubi.

“But we’re trying to make sure we have them as early as possible, during routine clinic visits.”

Canada leads the way in life expectancy for people with cystic fibrosis, and outcomes after lung transplant in Canada are the best in the world. Research that resulted from the discovery of the cystic fibrosis gene in Toronto in 1989 is coming to fruition with the availability of new medications to treat the gene defect that causes cystic fibrosis. During such an exciting and optimistic time for people with cystic fibrosis and their families, why focus on advance care planning?

“We believe that it’s important to understand our patients’ priorities and wishes at all stages of their illness,” said Dr. Elizabeth Tullis, director of the Toronto Adult Cystic Fibrosis Clinic. “Honest and open dialogue will ensure that there are no misconceptions and that all treatment options are discussed. Our goal is to help our patients live as long as possible with the best quality of life.”

“We asked our Cystic Fibrosis Patient and Family Advisory Committee how we should talk about end of life with patients,” said RN Jessie Chiu. “They agreed that it’s never too early, and they liked the idea of having education materials in the clinic rooms.”

Appiah-Kubi and Chiu developed brochures and posters for the outpatient clinic with information and tips for planning for end of life. A new checklist in the patient’s chart prompts members of the care team to ask the patient about his or her wishes, and keeps track of the points discussed.

Who will be the patient’s substitute decision-maker? What kinds of interventions do they want or not want at end of life (e.g. medications, intubation, etc.)? Once these decisions are made, the patient can update them at any time. The conversation often continues at subsequent clinic visits, or if the patient is hospitalized.

Until now, conversations about a patient’s wishes for end of life happened on a case-by-case basis – often when there was a sudden change in the patient’s health.

“Sometimes patients worry that we’re bringing it up because things look bad, or because there’s something we’re not telling them,” said Appiah-Kubi. “That’s part of why our RNs, social workers and physicians were leaving the conversation until later. Now, we start off by explaining that this is part of our regular assessment; we ask everyone to plan for end of life as early as possible.”

However, starting the discussion when patients are well gives them more time to think through their options, and to ensure that their families and the care team are on the same page.

Early advance care planning is a Registered Nurses’ Association of Ontario best practice. St. Michael’s has been a RNAO Best Practice Spotlight Organization since 2012.

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

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Dr. Elisa Greco first in Canada to perform vascular procedure using new device

By Leslie Shepherd

Dr. Elisa Greco is the first surgeon in Canada to use a recently approved device to provide permanent hemodialysis access for patients with end-stage kidney disease whose existing access is blocked or damaged.

It’s called the Hemodialysis Reliable Outflow graft device or HeRO Graft and it’s designed for patients who have exhausted all other access options.

Before starting hemodialysis, most patients undergo a procedure in which a surgeon connects an artery and a vein in the arm, creating a “fistula” to allow as much blood as possible to flow out of the body to be filtered by the hemodialysis machine.

But many patients are not candidates for a fistula because their veins are too small or they have stenosis, or narrowing, in spots. Some may have a graft implanted, artificially connecting the artery and the vein.

But if all those options fail, there is the HeRO Graft, and Dr. Greco, a vascular surgeon, has implanted many of them. The company newly redesigned the product, which was recently approved in Canada and she has implanted this in two patients so far. With longer term outcomes in patients with HeRO Grafts the company had noted common complications associated with the initial graft design.

Dr. Greco made all the arrangements for the first one during her last week on maternity leave and did the procedure her first week back.

The graft is made up of two parts, both of which are completely implanted under the skin. Using a type of imaging called fluoroscopy, which shows a continuous X-ray image on a monitor, Dr. Greco first made a small incision in the neck and fed a catheter through a large vein into the right atrium of the heart. The catheter is then threaded or tunneled under the skin to the front of the shoulder.

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Vascular surgeon Dr. Elisa Greco holds a T-shirt with an image of the HeRO Graft she implanted.

The second step is to insert a dialysis graft through the arm, where the dialysis needle will later be inserted. One end is sewn to an artery and the other is connected to the catheter. Blood starts flowing between the two as soon as they are connected.

The Ontario Renal Network recognizes St. Michael’s as a Centre of Practice for dialysis access.

Dr. Gary May performs an endoscopy at St. Michael’s Hospital. A new stent will allow Dr. May and other gastroenterologists to expand the number of patients on whom they can operate using a scope. (Photo by Yuri Markarov, Medical Media Centre)

New stent expands treatment options for critically ill patients

By Kelly O’Brien

Gastroenterologists at St. Michael’s Hospital were the first in Ontario to use a new type of stent to treat complicated cases of pancreatitis and severe infection in the bile ducts or gallbladder.

form of cysts near the stomach. The fluid and tissue are relatively easy to remove using a traditional plastic stent and a scope, so long as the cyst and stomach are stuck together.

The stent also allows gastroenterologists to treat patients at the bedside using an endoscopic ultrasound, expanding treatment options for those in the intensive care unit who are too sick to be moved or to have major surgery.

The Hot-AXIOS stent is a lumen-apposing metal stent, or LAMS, made of a coated woven metal alloy instead of plastic. Its shape, similar to that of a dumbbell, allows it to be deployed through an ultrasound scope. It brings the stomach and cyst together to prevent dead tissue from leaking into the body when draining the cyst, which reduces complications.

The stent, known as a Hot-AXIOS stent, is used in the United States and Europe, but is not yet approved for use in Canada.

St. Michael’s was the first hospital in Ontario to get “batch approval” from Health Canada for eight stents, to be used where doctors otherwise wouldn’t have been able to treat the patient.

Dr. Jeff Mosko performed the first procedure using the stent in January, alongside Dr. Gary May, division head of gastroenterology at St. Michael’s. Both participated in specific training before being granted the batch approval.

“This stent allows us to expand the number of patients we treat and reduces the number that need major surgery because we can operate through the scope on patients who we wouldn’t have been able to before,” said Dr. May. Pancreatitis is a condition in which the pancreas becomes inflamed, and in severe cases, can cause fluid and dead tissue to collect in the

Dr. May said there were some huge advantages to using the new stent.

“It facilitates further treatment, and allows for the procedure to be performed in one step,” he said.

“When extra steps are eliminated, it reduces the time for the procedure, and it can be done without the need for X-ray, which opens up the options of where we can treat the patients.”

But there are disadvantages, the main one being the cost. The HotAXIOS stent is significantly more expensive than other stents.

“It’s not something we’re going to start using in every case, but certainly we can use it when we can’t proceed with our standard techniques, or using this stent would significantly minimize the risks for the patient,” said Dr. May. MAY 2017 | IN TOUCH | 5

Steven Trentin, a lead plumber, prepares a heat exchanger for a shutdown. The device uses steam to heat water, which is then pumped throughout the facility to heat the hospital. (Photo by Katie Cooper, Medical Media Centre)

How planned shutdowns keep the hospital running

By Kate Manicom

Hidden behind the walls and above the ceilings at St. Michael’s are the systems essential to providing patient care, powering lights on the helipad, transferring steam to sterilize equipment and pumping medical gas to the ICUs. Both regular hospital maintenance and construction require planned shutdowns of hospital systems. When service is added or eliminated, like connecting power to a renovated clinic or removing obsolete pipes, the electricity must be turned off or pipes fully drained to safely do work. The Engineering and Plant Services Department has completed more than 500 shutdowns specifically for the 3.0 construction and renovation project since it started two years ago.

“A shutdown is not just a quick flip of a switch; each one is unique,” said Quinton D’Mello, manager of Engineering and Plant Services. “The type of service affected, the wing of the hospital, even the weather, are all factors in the timing and duration of a shutdown. They require planning, coordination and communication. But the number one priority is ensuring patient care is unaffected.”

After receiving a shutdown request from the contractor, the Engineering team reviews the hospital’s as-built drawings to understand the impact of the shutdown. As-built drawings show all the changes that have been made to a building’s systems since it was constructed. Due to the age of some parts of the hospital, MAY 2017 | IN TOUCH | 6

plumbing as-built drawings are sometimes unreliable because of the condition of the drawings or because they don’t reflect small changes made over the years.

When the full impact of a shutdown can’t be determined by drawings, Engineering investigates in person, opening walls or ceilings to see how the services have been laid out. This work is done in consultation with Infection Prevention and Control and the affected unit.

Shutdowns are often completed at night, when reduced water supply or changes in temperature will be less likely to affect patient care. No matter the hour, the Engineering team is on site to monitor. A plumbing shutdown may require a fire watch if water is cut to sprinklers. Shutdowns affecting sterile areas need to be closely observed to ensure humidity and temperature levels do not exceed levels where bacteria can grow.

Communication between all parties is key, said D’Mello. Staff in affected areas must feel prepared and understand the scope of work. The Engineering team must also be in close contact with the contractor to know when the work will start, end or if problems arise in the midst of the shutdown.

“Shutdowns take time, both to prepare and to execute,” said D’Mello. “But ideally when a shutdown goes well, no one will notice it.”

Angelo Tucci stands on the spot where he helped a woman who had delivered her baby in the front seat of her car.

(Photo by Katie Cooper, Medical Media Centre)

Baby-proof vest: Info Desk staff member helps with two births in one year

By Kelly O’Brien

Angelo Tucci has worked at the St. Michael’s Information Desk for 15 years, and when he witnessed a baby being born in the Queen Street lobby, he thought he’d seen it all.

Tucci got his vest back, and said it was lucky he did. About a year later, he would need it again.

Little did he know that within a year, he would witness a second birth in nearly the same spot.

In February 2017, a family had driven all the way from Oshawa, but before the mother could get out of the car, she had delivered the baby herself.

In early 2016, around 8:45 one night, Tucci was finishing his shift when he noticed a pregnant woman on the floor in the lobby. As he approached her he knew something was wrong.

“I asked her, ‘Are you okay? Did your water break?’ And she nodded, ‘Yes’,” he said.

He immediately called Obstetrics and Gynecology to send someone down. Then he grabbed a pair of gloves from behind the desk and waited, comforting the mom-to-be.

“The second time, it seemed like a movie,” he said.

“I just helped lift the baby onto her belly, and then ran back inside to get someone to call a code,” said Tucci.

Obstetrician Dr. Howard Berger was on the receiving end of that call. He said babies have been born in all different areas of the hospital, but that no matter how or where a woman in labour arrives, staff are prepared to respond.

From there, he said, everything happened quickly. He and a resident who was passing by laid the woman down. Having nothing else to catch the baby in, Tucci offered his vest.

“We know this is a possibility, so we have the people in place to ensure mom and baby are safe,” Dr. Berger said. “But if a baby is born in the Second Cup, I think they should get free coffee for life.”

“You know that expression, a bouncing baby? They really do bounce. It bounced right into my vest,” he said.

Tucci said he was in such shock that he never got the names of the families, but that he’s happy he was able to help.

The obstetrics team arrived shortly after, carrying mother and child—and his vest—away.

“It was such a crazy experience, but I’m glad it happened. How many times do you get to see that if you’re not a father?”

“As they were putting her on the stretcher, the father walked in,” Tucci said. “He had just dropped her off and gone to park the car across the street. It all happened that fast.”

He’s also glad he got the vest back.

“I told security, ‘Your vests are bulletproof, but mine is baby-proof.’”

There is an emergency button on the 15th floor so the obstetrics team doesn’t have to wait for the Cardinal-Carter elevators.

But Dr. Howard Berger didn’t need it in this case—when he called the elevator, it was there immediately.

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Q&A

STEPHANIE LUCCHESE REGISTERED NURSE, PSYCHIATRIC EMERGENCY SERVICES

(Photo by Katie Cooper, Medical Media Centre)

By James Wysotski

Stephanie Lucchese is an RN in the Emergency Department who specializes in crisis intervention. She’s championing the implementation of a Registered Nurses’ Association of Ontario Best Practice Guideline to help nurses better respond to patients in crisis.

Q: What are some of the biggest challenges you face in your role?

psychiatric care and mental status assessments at the same time.

Before now, there wasn’t anything like this role in Toronto’s downtown hospitals. It exists in the United States, England and Australia, but they don’t have mental health units in their EDs. I’m excited because now we’re going to have both.

Q: What are some of the challenges your patients face?

We’re an inner-city hospital and the social determinants of health affect our patients’ mental status and well-being. So we’re not just looking at their mental health, we’re looking at social issues such as housing – and there isn’t a lot of housing available for homeless patients. Some outpatient resources have such long waitlists that it’s hard to connect patients to the resources that will help them.

Our patients are concerned about stigma. A lot of patients won’t seek psychiatric help because they fear the label caused by a diagnosis and how it will affect their daily life. It’s sad, because the earlier they get treatment, the higher their chances of continuing to be high functioning. Some patients choose not to take medications and it has a negative effect on their lives.

Q: What changes are you leading in Psychiatric Emergency Services?

Q: The Emergency Department expansion is underway. What are you most looking forward to about the new space?

My quality improvement initiative suggested that crisis RNs should provide holistic assessments across the ED, but especially in psychiatry. As a result, we’re creating a role called the mental health nurse liaison. This nurse will follow mental health patients through the ED and provide them with psychiatric care. It’s particularly important for mental health patients visiting the hospital with physical ailments that require treatment first. These patients are usually triaged to ambulatory and acute care, but now the mental health nurse liaison can move with them to provide

Our new Mental Health Emergency Services Area will be its own unit with more beds. We see a high volume of patients every day, so more beds means we can respond faster to patients with a mental crisis.

INTOUCH

MAY 2017

In Touch is an employee newsletter published by Communications and Public Affairs.

Please send story ideas to In Touch editor Leslie Shepherd at shepherdl@smh.ca.

Design by Lauren Gatti

Q: How do you unwind after stressful days in the ED? I love to travel. I try my best to travel as often as possible with my husband, to see new things and recharge my batteries. If we don’t take care of ourselves, it’s hard to take care of others.