In Touch newsletter: November 2017

INTOUCH NOVEMBER 2017

Infection preventionist Shara Junaid discusses a new influenza patient with an Emergency Department nurse.

(Photo by Yuri Markarov, Medical Media Centre)

Systems, software and a need for speed: Tracking and preventing influenza’s spread

By Emily Holton

Infection preventionist Shara Junaid is at her desk when the phone rings.

It’s the hospital lab. A patient in the Emergency Department has tested positive for Influenza A. Junaid used to respond by creating a case profile by opening the patient’s electronic medical record and cutting and pasting details into a new Excel spreadsheet. Today, thanks to RL6:Infection software by the Canadian company RL Solutions, Printed on 100 per cent recycled paper

the lab results have already popped up on her computer in an alert, and the patient’s details are already on her desktop when the lab calls.

Junaid is one of the infection control professionals who provide 24-7 coverage for infection prevention emergencies at St. Michael’s as well as education, surveillance and policy development.

While the patient’s care team is responsible for isolating and treating the patient, the Infection Prevention and Control Team helps track and prevent an infection’s spread.

First, Junaid needs to know the patient’s basic clinical details.

“This software can pull info right away from the patient’s electronic medical record, info that we would otherwise have to find manually,” said Junaid.

“We can create new profile in just a few clicks, with much less room for error.”

The patient’s history shows that he was discharged from St. Michael’s Orthopedics Ward the previous day.

This means that Junaid must quickly Continued on page 2 NOVEMBER 2017 | IN TOUCH | 1

OPEN MIKE with

Dr. Bob Howard

President and CEO (interim) the new network board.

People may see me as the boss, but I like to remind them that I, too, have a boss, our board of directors.

I am accountable to the board (as is the rest of the senior leadership team) and the board in turn is accountable to our patients and the public at large.

That’s why when we began the process of integrating Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital, one of the first and most important steps was to create a new board of directors.

We asked members of the three “legacy boards” who wanted to be on the new network board. A small panel of three retiring board members worked with a third party to meet with the candidates to determine the final 16 people, based on a skills matrix, who would make up

The new board spent its first couple of meetings getting organized and acquainted to help members function as a new team. Board members toured each of the three sites and held a retreat, which was also attended by the Catholic Health Sponsors of Ontario and the Sisters of St. Joseph.

As vice-chair Colleen Johnston has said, integration is a bit like blending families.

Everyone comes to the new kitchen table or holiday dinner with their own deeply held traditions and firm beliefs in the right way of doing things. But the new experiences and new beginnings that are part of being a new entity provide opportunities to create new traditions.

And that’s where the new board is leading by example.

One of the first jobs of a board of directors is to make sure it has the right CEO in place. So one of its priorities is to find my replacement!

Systems, software story continued from page 1

patient and their current location.”

trace the patient’s contact history to identify other patients in the ward who may have been exposed to the virus.

About 15minutes later, Junaid is ready to notify units which patients may have been exposed to the influenza virus. At minimum, they’ll be isolated and closely observed for the next few days.

“We used to have to print out and manually review hospital censuses for every day the patient was in hospital and considered infectious,” said Junaid. “But now that our software is integrated with our Admission, Discharge and Transfer System, I can generate a list of previous roommates within minutes: who they were, how long they were in contact with the NOVEMBER 2017 | IN TOUCH | 2

The board hired the executive search firm Egon Zehnder to conduct an executive search for the best person to complete the integration of our network and lead us forward. The firm has already met with more than 100 people or groups as part of its stakeholder consultation.

Governance was another top priority for the new board. Board members set up subcommittees to help them do their work overseeing quality, planning and construction, research, education, and resources,to make sure the network continues to run well, meet its financial obligations and its obligations to patients and the public to provide high-quality patient care.

Board members are all volunteers.

They volunteer their time – lots of it – and their considerable expertise from a wide range of industries and community service. We are so lucky that each one of them chose us.

sources means we can investigate and act much faster.”

“We’ve always had access to the lab system, the medical records system and the admission, discharge and transfer system,” said Junaid. “We had our own documentation as well, but the process of integrating and documenting all the data was time consuming. To be able to use a single program to access, pull from and generate reports from all these Follow St. Michael’s on Twitter: @StMikesHospital

Advanced practice occupational therapist Maureen Riley examines the hand of patient Glenn Forde. (Photo by Katie Cooper, Medical Media Centre)

New hand clinic provides care ‘at the right time from the right person’

By James Wysotski A new, streamlined referral process means less waiting for patients with hand injuries.

Since the creation of the Advanced Practice Occupational Therapy Hand Clinic in summer 2016, patients with issues such as simple fractures, joint injuries, tendonitis, arthritis or carpal tunnel syndrome can be referred directly to an occupational therapist instead of being sent first to plastic surgeon Dr. James Mahoney. As a result, wait times are usually one or two weeks instead of up to six.

Maureen Riley, an advanced practice occupational therapist, said it’s all about getting care for patients at the right time from the right person. She said there was too much of a delay with the old system, especially since Dr. Mahoney usually referred patients to an OT anyway. By the time she saw them, they were often stiff, with functional limitations, pain and swelling, which made treatment more difficult.

Instead, physicians from the Emergency Department can refer patients to Riley directly. A certified hand therapist, she

assesses them and develops treatment plans that can include home-exercise programs to build strength and flexibility, splinting and ways to manage swelling. She also prescribes assistive devices to make life easier, such as special jar openers. During followup care, Riley also lets patients know when it is safe to resume life activities and sports.

If needed, she refers them to the hospital’s Occupational Therapy Department for formal hand therapy. Any problems can have an expedited referral to Dr. Mahoney.

best treatments “toThe get hands functioning as fast as possible are supervised education and exercise instruction.

” – Dr. James Mahoney

“I’m proud to be able to use my skills and knowledge in the clinic, and having a more autonomous role allows me to treat patients promptly and get them back to their daily lives faster,” said Riley.

If patients’ problems persist after completing all rehab options, they can be referred to Dr. Mahoney to determine next steps. He said it’s rarely necessary and that the new clinic benefits his practice by allowing him to focus more on his surgical cases.

“Having the new clinic frees me up to see another 10 patients a week who need a medical procedure,” said Dr. Mahoney.

“It has increased the scope of my practice significantly.”

Riley fashioned the clinic, the only one of its kind in Toronto, after the Advanced Clinician Practitioner in Arthritis Care Program, which aimed to improve wait times by training experienced physical and occupational therapists and nurses. As demand for the clinic’s services increased, it changed from bi-weekly hours to weekly.

“Having this clinic has been tremendous because it allows me to see patients sooner and help prevent longer-term problems,” said Riley.

NOVEMBER 2017 | IN TOUCH | 3

Johanna Macdonald (right), the first lawyer with the Health Justice Initiative, provides legal counsel to Sofia, a patient at one of the hospital’s family health team sites who received a “prescription” from her doctor to see Macdonald for her health-affecting legal issues.

(Photo by Yuri Markarov, Medical Media Centre)

Bridging the gap between health care and legal services for patients

By Skaidra Puodziunas

It’s not just doctors and other healthcare providers who see patients at St. Michael’s six family health team locations.

As part of a first-in-Canada Health Justice Initiative, patients also have access to an on-site lawyer and legal students who can help them with a wide range of health-affecting legal issues such as precarious employment or housing, family law and immigration matters.

The initiative has seen more than 600 patients.

“Most often clients I see can’t even begin to address their health concerns because they’re dealing with basic housing rights issues, for example,” said lawyer Johanna Macdonald, who saw patients from all the FHT sites. Macdonald recently left to NOVEMBER 2017 | IN TOUCH | 4

become executive-director of Parkdale Community Legal Services; a search is underway for her replacement.

“By providing legal assistance in a hospital community clinic setting, communication channels between health-care providers and legal teams open up,” Macdonald said.

“The health justice partnership has helped us to recognize the impact legal issues have on a person’s health and well-being,” said Dr. Karen Weyman, chief of the Department of Family and Community Medicine. “By being able to address a patient’s legal issues, we often see their overall health improve.”

The Health Justice Initiative is the first partnership in Canada between a hospital and a community legal clinic. Macdonald was employed by Neighbourhood Legal Services and Legal Aid Ontario funds the position. The other legal clinic partners are the ARCH Disability Law Centre, Aboriginal Legal Services of Toronto and HIV & AIDS Legal Clinic of Ontario.

Macdonald said the Health Justice Initiative helps patients feel more comfortable opening up about legal issues in the clinic because it has a less intimidating environment than a formal law office. Most patients are referred to her by their primary health-care providers. However, patients can also contact the lawyer directly or attend a weekly drop-in clinic run by law students.

The legal initiative is part of a larger strategy at St. Michael’s to address the social determinants of health—the circumstances in which people are born, grow up, live, work and age, all of which impact their health and overall well-being.

“We deal with highly sensitive and complex issues daily,” said Macdonald.

“But the key is to listen and respond with compassion. It’s an honour and privilege to be a part of this project. I truly feel I’m making a difference for my clients.”

Dr. John Lee explains the Sniffin’ Sticks test to patient Jeremy Phillips in the Sinus and Nasal Physiology Lab. (Photo by Katie Cooper, Medical Media Centre)

Non-invasive test could be a marker for healthier sinuses

By Greg Winson

Chronic sinusitis is an inflammatory disease that affects five per cent of Canadians. Patients can feel like they have a cold for months on end.

One of the challenges for physicians treating sinusitis is selecting the best treatment. Some patients respond well to nasal sprays or antibiotics, while others require surgery for relief. Nitric oxide may provide the answer.

“Nitric oxide is a gas normally produced by our sinuses,” explained Dr. John Lee, an otolaryngologist-head and neck surgeon and director of the Sinus and Nasal Physiology Lab at St. Michael’s Hospital. “It’s there to help fight bacteria and viruses in our sinuses.”

A study by Dr. Lee, with colleagues in the Division of Respirology, show that nasal nitric oxide levels may be a biomarker for sinusitis. Healthy sinuses have higher nitric oxide levels than patients with evidence of inflammation or infection. The non-invasive test that measures nitric oxide takes just 20 minutes to perform.

Research performed at the Sinus and Nasal Physiology Lab, the only lab of its kind in the Greater Toronto Area, informs patient care and treatment.

“The more we are able to objectively know what’s going

on in the sinuses, the better we can tailor the appropriate treatment,” said Dr. Lee. St. Michael’s was one of the first hospitals to have a nasal airflow laboratory. In the 1980s, otolaryngologist Dr. Philip Cole designed the first airflow measurement that in its time was a standard for measuring airflow and resistance through the nose.

Did you know?

Nitric oxide was named Molecule of the Year in 1992 by the journal Science.

When Dr. Lee arrived at St. Michael’s in 2009, he set about reviving the lab using newer, non-invasive devices to provide a comprehensive assessment of sinus and nasal function.

In addition to airflow, the Sinus and Nasal Physiology Lab also assesses patients who complain of a lack of smell. The lab performs a test with 16 common scents in the form of sniffing sticks that can objectively measure smell function.

NOVEMBER 2017 | IN TOUCH | 5

Intrahospital TOA: Safe transitions for a safe system Leushuis co-led a pilot of the e-ticket and associated decision-making guidelines in Hematology/ Oncology, along with Suzanne Scotland, a registered nurse and best practice champion. Nephrology, Patient Transport and Medical Imaging also piloted the tools. The project contributed to the hospital’s implementation of the Registered Nurses’ Association of Ontario Best Practice Guideline to promote safe and effective care transitions and built on the successful work to implement hospital-wide, shift-toshift transfer of accountability.

“The e-ticket doesn’t replace our telephone communication, but it guides the questions the receiving unit or area can ask,” said Scotland. “They can see all the pertinent information right away, and then use the phone call to verify it with us. I feel that this is the key to implementing a BPG. For it to be successful, you have to tie it into the work you already do. We weren’t reinventing the wheel, we were articulating, standardizing and improving the way we already provide care.”

We weren’t reinventing the “wheel, we were articulating, RNs Carl Leushuis and Suzanne Scotland double check the name on a patient’s wristband before he goes to Medical Imaging.

(Photo by Yuri Markarov, Medical Media Centre)

standardizing and improving the way we already provide care.

- Suzanne Scotland

”

By Emily Holton

A new e-ticket is helping to ensure that when inpatients move between non-critical patient care areas, their safety information is front-and-centre when they arrive.

“Before now, we would call the receiving unit or area to make sure they had the details about the patient that we thought were of note,” said Carl Leushuis, a registered nurse and best practice champion in Hematology/Oncology.

The pilot was part of an ambitious research, education and quality improvement initiative to develop and implement the e-ticket and associated decision-making guidelines to ensure safe transfer of non-critical patients. The project required education, engagement and practice change among front-line staff across the hospital: registered nurses as well as patient-transport assistants and health disciplines, clerical and medical imaging staff. A hospital-wide research project is evaluating staff perceptions of the tool and guidelines.

“However, working on the project, it became clear that the information we were choosing to highlight for each patient was very subjective. What we thought was important for the Medical Imaging staff to know may not have been what they actually needed to do their work and keep the patient safe in their context.”

“There are always new initiatives – it’s a challenge to keep up with them as a staff member,” said Scotland.

“But we’ve generated a lot of buy-in through our education and advocacy, so it feels like we’re set up for success.”

If the patient is at risk of falling, needs special equipment or extra infection-control precautions, this information is automatically pulled from his or her electronic medical record and highlighted in the e-ticket for transfer.

NOVEMBER 2017 | IN TOUCH | 6

Emily Sestito, a nurse on 8 Cardinal Carter South, shows infection preventionist Lisa Bunn a supply caddy on the peritoneal dialysis machine cart. Keeping supplies with the PD machine, which is moved around the unit, helps to eliminate clutter in patient rooms.

(Photo by Yuri Markarov, Medical Media Centre)

Everything in its place

By Kate Manicom

“Paging Marie Kondo...”

The Nephrology/Urology team on St. Michael’s Hospital’s eighth floor has learned the magic of tidying up.

After decluttering patient rooms, hallways and nursing stations, along with increased collaboration between nurses, Infection Prevention and Control and the Environmental Services team, the unit has not had a hospital-acquired case of C. difficile since June 2017.

The C. diff. bacterium is the most frequent cause of infectious diarrhea in hospitals. It is spread by touching contaminated surfaces or improper hand hygiene. For healthy people, C. diff. may not pose a risk. But patients like those found on the Nephrology Urology Unit – who are immunocompromised due to dialysis or organ transplant, are already on antibiotics, and are often elderly – are at a greater risk of infection.

After months of struggling with clusters of cases of C. diff., IPAC recommended that the unit address clutter on the unit.

“There’s evidence that hospital cleaning can be linked to outbreaks, and if there is clutter, the environment cannot be cleaned effectively,” said Lisa Bunn, an infection preventionist at St. Michael’s who worked with the team on 8 Cardinal Carter South to address the levels of C. diff.

In patient rooms, care supplies, cleaning products and personal items could be found lining window sills, bedside tables and washroom sinks, making it challenging for the hospital’s Environmental Services team to properly clean surfaces. Common areas such as the nursing station and hallways were filled with equipment and the back room of the nursing station was cluttered with staff belongings and personal items left behind by patients.

The unit’s Clinical Leader Manager, Colleen Johns, asked Emily Sestito, a

nurse on the unit, to take the lead on implementing specific changes, including educating staff and patients, and reducing clutter in patient care and staff areas.

“I worked closely with Lisa to develop education sessions for our team about C. difficile and how it’s spread,” said Sestito.

“And we’re actively educating patients and families about the importance of hand hygiene and keeping surfaces – particularly in the washrooms – as clear of personal belongings as possible.”

The EVS team has also introduced new cleaning supplies and, with the help of improved communication between unit staff and EVS workers, have added protocols for rooms where a patient with C. diff. has stayed.

After decluttering, the unit received a thorough cleaning, including equipment such as workstations on wheels. The team is still doing regular audits of their space and hopes their lessons learned will be helpful for other units in the hospital.

“It’s like keeping order in your own home: a place for everything and everything in its place,” said Sestito.

NOVEMBER 2017 | IN TOUCH | 7

Q&A

By Emily Holton (Photo by Yuri Markarov, Medical Media Centre)

MICHAEL SZEGO,

DIRECTOR, CENTRE FOR CLINICAL ETHICS

Q. Tell us about the role of the clinical ethicist. What do you do?

Our role is to help patients and care providers make decisions when the moral, “right thing to do” isn’t obvious. We also take part in clinical rounds, develop policy, deliver education, do research and are members of hospital committees like the Research Ethics Board.

Q. What does a typical consult look like?

We sometimes get consulted when a patient or family is struggling with the choice between continued aggressive care and a palliative approach. If possible, I would start by talking with the patient about his or her wishes. If that’s not possible, I talk with the family members about what they think the patient would want. This can be really difficult. It’s so hard to separate what we want for our loved one from what they would want for themselves. If the patient is not capable, my job is to, along with the interprofessional team, help the substitute decision-maker reorient to his or her new role as a conduit for the patient’s wishes. I don’t go in with any pre-conceived ideas about what the right answer is. I’m just here to help them work through this big decision.

Q. Tell us about the Centre for Clinical Ethics.

The Centre for Clinical Ethics is a partnership between St. Michael’s, St. Joseph’s Health Centre and Providence Healthcare.

The partnership predates our integration. We are a team of

INTOUCH

NOVEMBER 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 Marcelo Silles, Medical Media Centre

seven clinical ethicists and one fellow that provides ethics services to nine different health-care organizations across the GTHA.

Q. What’s the most gratifying part of your job?

Those moments when I know I’ve helped people make a really hard decision, even if the outcome is sad. People often assume my job is really sad. But if the family feels that we’ve come to the right decision, and that we’re honouring a patient’s wishes and values, it feels good to have been a small part of that.

Q. What do you do for fun?

I have three kids, aged six, seven and nine. They love skating and can’t wait until our community’s skating rink opens this winter. I also really like growing orchids. I have a collection of 12 at home.

Part of my undergrad at McGill was in botany, and I used to love visiting the orchid room in the greenhouse on top of Stewart Biology Building on Mont Royal in Montreal.

Q. How do you describe your job to your kids?

When they ask about my job, I tell them that I help people make hard decisions. If they ask why the decisions are hard, I am honest and say it’s because “sometimes people make decisions that will make them live less long.” They accept that. We’re pretty open about life and death in our house. We’re always honest but don’t give them more info than they’re asking for. More often than not, they’re not looking for a lot of details. When my son asked me what happens when you die, I said, “Your body stops working.”

He was totally satisfied with that.