INTOUCH NOVEMBER 2016
Dr. Steve Lin washes his hands in the Emergency Department, where RN Jodi Den Bok shows her new badge to patient Manohar Lai Verma. NOD and Wave is a new ED initiative to encourage staff to practice good hand hygiene and introduce themselves and their roles to patient. (Photo by Yuri Markarov, Medical Media Centre)
NOD and Wave: Improving communication and hand hygiene in the Emergency Department By Kaitlyn Patterson
Visiting the Emergency Department can be a scary experience, especially if patients don’t know the name or role of the health-care professional treating them. Focus surveys conducted in the ED with patients and staff at St. Michael’s Hospital found that being able to identify staff and their roles is highly important to patients. To address this, an ID badge pilot project with an education component called NOD and Wave is underway in the ED. When staff meet with a patient, they now introduce themselves with NOD: name, occupation and duty, a concept adapted from Thunder Bay Regional Hospital. For example, “My name is John. I’m a nurse and I will be taking your blood pressure.” Printed on 100 per cent recycled paper
“Wave” is an original component that was added to the project at St. Michael’s to remind staff to wash their hands before interacting with a patient. “It can be confusing for patients because we all wear the same uniform and often have crossover in our roles,” said Lee Barratt, a clinical nurse educator in the ED. “NOD and Wave reminds us to identify ourselves to patients, explain what we will be doing and to practice hand hygiene.” New colour-coded ID badges with larger occupation titles, larger names and smaller photos are being used to identify staff. The colours on the badges match posters in the ED, which provide patient-friendly descriptions of the project and the role of each occupation. For instance, if a staff member is wearing a badge with a light blue stripe, it means he or she is either a resident doctor or medical student. Patients can read one of the posters to gain
a better understanding of what the health professional’s role involves and with whom he or she typically works. “Our goal for this project is to minimize patient confusion,” said Anthea Tseng, a quality improvement analyst. “We’ve emphasized the provider’s name and role on the badge and selected a handful of colours to identify the different groups of providers who work in the ED.” Other departments such as the Diabetes Clinic and Breast Centre have also administered surveys to patients to determine if the project should be extended beyond the ED. “So far, we’ve received all positive feedback regarding the ID badge project and the NOD and Wave component,” said Tseng. “It gives patients comfort knowing that the staff is focused on improving open communication and hand hygiene within the hospital.” NOVEMBER 2016 | IN TOUCH | 1
OPEN MIKE with Dr. Arthur Slutsky,
Vice-President, Research enrolling patients and collecting samples for research.
November is Research Month at St. Michael’s. We’re celebrating this month not only in the Li Ka Shing Knowledge Institute and Keenan Research Centre for Biomedical Science, but across St. Michael’s Hospital. This month is an opportunity to recognize everyone involved in research at St. Michael’s. I want to take the time to thank our scientists, coordinators, lab managers, students and trainees for their role in shaping St. Michael’s research enterprise and contributing to the improved health of our patients and community. Of course research doesn’t end at the LKSKI doors. This month we also celebrate the nurses, occupational therapists, social workers, lab technicians and all the other health professionals designing protocols,
research project asking hospital physicians, staff, students and volunteers how research could help improve patient care. Five hundred participants, representing 18 hospital departments, shared their thoughts. These results will be shared Nov. 10 at noon in the Allan Waters Family Auditorium.
Where would our research be without the administrative personnel who schedule followup appointments required for trials or the supply chain manager who ensures scientists have the mediums they need at the same time their sample is ready? As members of an academic hospital, we are all a part of research, even if the only time you cross the bridge is for a Starbucks coffee. This month’s tagline is “Our research changes lives.” And “our” means ALL of us. To celebrate the impact that research makes on policy, practice and, most importantly, patients, several activities are taking place throughout the month that everyone is invited to attend. A full calendar of events is available on the intranet and the research website but I’d like to point out two: •
As part of the St. Michael’s Strategic Plan, Dr. Patricia O’Campo led a
•
Between 10 a.m. and 2 p.m. on Nov. 22, everyone at St. Michael’s is invited to tour the Keenan Research Centre for Biomedical Science laboratories. I strongly encourage you to take an opportunity to see some of the technology and people generating knowledge in basic science at St. Michael’s.
Our research changes lives. I know because I’ve seen discoveries transform care. The research taking place in the labs and clinics today will contribute to better outcomes for our patients tomorrow. We and our patients live research every day, let’s all celebrate it this November.
FIVE WAYS TO PREVENT FALLS IN YOUR AREA November is Falls Prevention Month! Some tips to remember all year: 1.
Make sure that every admitted patient gets a Falls Risk Assessment in Soarian – no matter which clinical area he or she arrives from. Sometimes the assessment is needed to spot the risk.
If a patient is a falls risk: 2.
Complete a SIMPLE tool! Document all the great work being done to prevent falls.
3.
Before leaving a patient’s room, get in the habit of asking if he or she needs help with toileting.
4.
A patient’s call bell should be within their reach. However it’s also important to make sure the patient can demonstrate that he or she knows how to use the call bell properly.
5. Involve the patient’s family. They can share the falls-prevention strategies that have worked for the patient at home. NOVEMBER 2016 | IN TOUCH | 2
Follow St. Michael’s on Twitter: @StMikesHospital
A more thoughtful approach to routine blood testing By Emily Holton
A St. Michael’s hematologist is asking physicians to think twice before ordering routine bloodwork. Losing just a few milliliters of blood per day – about one full tube’s worth – increases risk of anemia. Among hospital patients, anemia is associated with longer length of stay, blood transfusions and even death. Not to mention that every poke hurts, and every test costs money. Dr. Lisa Hicks, a hematologist and Choosing Wisely lead at St. Michael’s, wanted to see if there was room to reduce repetitive, “routine” blood testing at St. Michael’s. Routine bloodwork usually consists of a complete blood count, biochemistry tests and coagulation tests. “We’ve all been trained to put great emphasis on data collection to inform care, and that’s a positive thing,” said Dr. Hicks.
“However, sometimes it can err on the side of excess.”
weren’t unintentionally encouraging openended orders.”
Dr. Hicks and her team found that about one-half to two-thirds of patients on General Internal Medicine and Hematology/Oncology had routine bloodwork completed on at least three consecutive days during their stay. Of those patients, one-third continued to receive daily blood tests after their numbers had stabilized. This suggested that some patients were getting tests that they didn’t need.
In May, she worked with clinicians to revise order sets that were used frequently on GIM and Hematology/Oncology. The aim was to ensure that time-limited orders were easier to make than open-ended orders. It’s still possible to order daily blood tests with no end date, but that option requires more keystrokes.
To respond, Dr. Hicks and her team zeroed in on order sets, checklists that bundle together medical orders (such as blood tests) for testing and treatment. “Technology can sometimes make it easy for us to act in a habitual pattern rather than a thoughtful pattern,” said Dr. Hicks. “We wanted to make sure the order sets
The initial results are encouraging. “Even though these changes are modest and can be worked around, we have seen a drop in routine blood testing,” said Dr. Hicks. “The clinicians have really embraced the idea.” Nurse practitioners Marnee Wilson and Bertha Hughes are now leading a revision of order sets for Cardiovascular and Peripheral Vascular Surgery, where threequarters of patients get daily blood tests.
Infographic by Marcelo Silles St. Michael’s is an RNAO Best Practice Spotlight Organization
NOVEMBER 2016 | IN TOUCH | 3
Taking down a staircase, building patient care
The Peter Gilgan Patient Care Tower at Queen and Victoria streets. Demolishing the Cardinal Carter South stairwell will allow the new tower to be connected to the existing hospital. (Photo by Yuri Markarov, Medical Media Centre) By Kate Manicom
At the corner of Queen and Victoria streets, the Peter Gilgan Patient Care Tower is closing in on its planned height of 17 storeys. The addition to St. Michael’s Hospital, specifically designed to care for critically ill patients, includes brand new spaces for emergency surgery, the Medical-Surgical Intensive Care Unit, Orthopedics and Respirology, among others. When it is linked to the existing hospital, efficient circulation routes between the wings will be created, and on some floors, new patient and family waiting areas will be built. But connecting the new addition to the existing hospital isn’t as simple as installing a door on each floor. Between the hospital’s Cardinal Carter wing and the patient care tower is a 17-storey concrete stairwell, which must be taken down at the end of the year to complete construction on the tower and then link it to the hospital. It is a complex project, requiring months of planning between teams in the hospital and the contractor responsible for the project. Coordinating hospital operations during construction is led by the hospital’s Operational Readiness Department. Alongside teams from across the hospital, Operational Readiness makes sure that all equipment continues to work during the stairwell demolition and all other aspects of patient care continue, including infection prevention and control and housekeeping. “Operational readiness is about making sure that each patient NOVEMBER 2016 | IN TOUCH | 4
has the right care, in the right space, with the right equipment and technology, at the right time, regardless of construction activities in the hospital,” said Margaret Moy Lum-Kwong, director of Operational Readiness. “Months of planning have gone into making sure we have the right tools and processes to carry out this work.” Every effort is being made to reduce disruptions during the project, including using alternative methods to remove the staircase. For example, separating the staircase away from the existing structure by sawcutting prior to crushing the concrete will help to reduce noise and vibrations from travelling through the building. “By installing noise and vibration monitors in key locations in the adjacent areas of the hospital, and working closely with our contractor, we can ensure the impacts of this work remain at safe levels. If necessary, we can adjust our demolition methods,” said Tom Parker, senior project engineer for Planning and Redevelopment. Particulates will also be carefully monitored. Stringent infection prevention and control measures will be in place, including installing hoarding and negative air machines to safeguard patients and others who are susceptible to infection. “The stairwell has to come down so that we can finish building something great,” said Moy Lum-Kwong. “While at times the work may be a bit noisy, safety and patient care remain our top priorities.”
Years built: 1994 and 1999
Volume of concrete: 2317m3 Height of stairwell: 78.9 metres
Number of stairs: 410
Number of floors: 17
Tools for safety: vibration and sound monitoring
Infographic by Lauren Gatti
NOVEMBER 2016 | IN TOUCH | 5
Teaming up to protect patients from malnutrition By James Wysotski
What does malnutrition look like? Not always what one might think.
meals reheated. And if volunteers or non-clinicians see uneaten meals, they’d know someone needs to hear a report.
“People have a picture in their minds of how a malnourished person looks, but sometimes patients who look well are at the highest risk,” said Jackie Song, a registered dietitian in the Cardiovascular Intensive Care Unit. For example, 24 per cent of overweight patients are at risk, according to the Canadian Malnutrition Task Force.
“It’s a team approach,” said Song. “We all have to work together to make sure conditions are optimal for faster recoveries.”
At St. Michael’s Hospital, one-third of all patients admitted are moderately to severely malnourished, said Song. The key is identifying them right away because malnutrition is associated with increased risk of death, impaired healing, more falls and longer stays in hospital. The process of identification is challenging because malnutrition is often a byproduct of social determinants of health or prolonged sickness with whatever caused the hospital visit. The instinct is to focus treatment on what’s diagnosed on admission, so Kim Bradley, the manager of Collaborative Practice and Education, said she wants to see malnutrition as a co-diagnosis. “It’s not just about getting the medicine to you because food has such an important role in getting you well,” she said. “Food is medicine.”
Registered dietitian Jackie Song assesses a patient to determine if she’s malnourished. (Photo by Katie Cooper, Medical Media Centre)
The newly formed interprofessional Nutrition and Hydration Working Group – which includes Bradley and Song – seeks to implement best practices for the identification and treatment of malnourished patients. This means screening all patients, increasing documentation and creating mealtime strategies for at-risk patients
More than 75 per cent of patients are satisfied with the food here, but one in three eats less than half. So what’s keeping them from eating?
“Screening is the big priority,” said Song. “If we can’t ID them, we won’t know who to prioritize.”
Patients say…
While screening already occurs in some settings, Bradley said she wants everyone to be screened when they are admitted as inpatients or visit a family health team – because the diagnosis isn’t made often enough. And then at-risk patients would see a dietitian for assessment and to document the diagnosis so that appropriate help is given. Early identification, when coded properly, ensures people get treated. One idea the working group is considering would be adding a diagnosis to the meal entry system so that a visual trigger such as a different-coloured placemat or meal tray would let staff know this patient needs to eat. Protecting patients at mealtime is a common thread to the group’s ideas because one in three patients eat less than half of their food. Reasons vary from being unable to open packages or reach food, to staff interruptions or being sent for procedures. The goal is awareness so that all staff takes ownership of improving patient outcomes. For example, once finished caring for a patient, they can ensure side tables are within reach or have NOVEMBER 2016 | IN TOUCH | 6
• • • • • •
40 per cent could not open the packages 23 per cent were poorly positioned to eat 22 per cent missed meals for procedures 18 per cent could not reach their meal 62 per cent were interrupted by staff during meals 34 per cent did not get replacement meals when missed • 13 per cent did not receive help when they needed it • 58 per cent did not get what they ordered • 42 per cent were disturbed by noises or smells
Peer support workers Sanda Kazazic (left) and Samuel Gruszecki discuss the week’s readings with program participant Dave Nolting (centre). (Photo by Katie Cooper, Medical Media Centre)
Reading for resilience By Evelyne Jhung
Having “lost everything” in B.C. after a particularly devastating manic episode, Dave Nolting found his way back to Ontario and to the STAR Learning Centre, a program that helps people transition from homelessness to housing in as smooth a manner as possible by allowing them to discover or rediscover activities that are meaningful to them. One of the programs is Reading for Resilience. “This is a highly beneficial program to be around because there are other people who’ve gone through similar adversities as you,” said Nolting. Each week, participants in the Reading for Resilience program listen to and discuss selected readings – which range from short essays to haiku – based on that week’s theme. Themes include compassion, courage, loneliness, love and hope. Spearheaded by Sandy Iverson, manager of the Scotiabank Health Sciences Library, the bibliotherapy program started its second session with the STAR program and St. Michael’s
Hospital’s inpatient Mental Health Unit in September. It doesn’t require any literacy level nor are participants obliged to do the readings in advance. “People find it calming to be read to – that in itself is therapeutic,” said Iverson. “Reading what other people have written, about loneliness or despair for example, and then discussing it helps participants recognize that they’re not the only ones going through this. People share their thoughts and interpretations, but also their own experiences.” The program is six weeks long and each session is limited to six to eight participants to allow for comfortable discussion. Iverson and another librarian co-facilitate the sessions and peer support workers from STAR and the inpatient Mental Health Unit attend. “It rehashes for me that you’re not alone in these thoughts of bleakness or feeling downtrodden,” said Nolting. “They’re fairly widespread, feelings even people who have jobs [as poets or writers] experience. It reaffirms in my mind that I’m not alone in this journey.”
“The common denominator among all of us is this idea of resilience. What is it and how can we build it to help us on our journey?” --Sanda Kazazic, peer support worker, STAR NOVEMBER 2016 | IN TOUCH | 7
By Geoff Koehler
Q&A
Dr. Sharon Straus is director of the Knowledge Translation Program at the Li Ka Shing Knowledge Institute and deputy physician-in-chief of St. Michael’s Hospital. She’s leading a research project assessing gender equity in medicine and research at St. Michael’s and the University of Toronto. Q: Is there gender equity in medicine and research? No, there’s not. At Canadian universities, women have outnumbered men for more than 20 years in undergraduate and graduate levels. But that trend doesn’t continue for more senior levels of academia. The higher the university rank, the lower the proportion of women. At St. Michael’s, 62 of our 206 research scientists are women. More than twice as many men as women are clinician scientists. Q: Why do these gaps exist? Unconscious bias is a contributing factor. How many of us, for example, have laughed at jokes about men being reluctant to ask for directions? Having biases doesn’t mean we’re bad people. Everyone is susceptible to unconscious stereotyping but it’s important to be aware of our biases so we can make efforts to minimize their influence. Q: What needs to be done to bridge the gender divide? We need to detect unconscious gender bias. Take the Harvard Implicit Association Test (http://bit.ly/genderequitytest) and see how you do. Institutional structures also contribute to the discrepancy. We need
INTOUCH
NOVEMBER 2016
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
DR. SHARON STRAUS DIRECTOR OF THE KNOWLEDGE TRANSLATION PROGRAM a formal mentorship program for our scientists. Role modelling by women scientists helps encourage trainees to consider this pathway. Inviting more women to present at research or grand rounds would create more opportunities. We need to standardize recruitment processes to ensure searches are equitable and transparent. Women need to be represented on search committees and all committee members, women included, need to be aware of potential for unconscious bias. Q: Is St. Michael’s making progress toward gender equity? We’re talking about this issue, which is a good sign. I’ve had the full support of the hospital’s research leadership and Department of Medicine in our work to close this gap but I don’t believe we’ll be “there” until our faculty reflects our training pool. It’s important to have women in leadership roles and Dr. Patricia O’Campo joined the Research Leadership Committee in April. The research institute will monitor recruitment and retention and will implement and evaluate strategies that we believe will bring a better balance. Q: Who is the female scientist in history you most admire? Rosalind Franklin is the person I admire most from history. Her X-ray studies contributed to the understanding of DNA’s double-helix structure but she passed away before the Nobel Prize was awarded for this work. As for active scientists, I really admire Dr. Deb Cook, who is a terrific researcher at McMaster University. Her work has impacted care worldwide and she’s an amazing mentor and a fantastic role model.