INTOUCH SEPTEMBER 2016
Kim Grootveld, case manager for the General Internal Medicine unit, and Hyunja Sung, a personal support worker for WoodGreen Community Services, help Cyril Moore into transportation for participation in WoodGreen’s adult day program. (Photo by Katie Cooper, Medical Media Centre)
Helping frail senior patients transition from hospital to home By Kaitlyn Patterson
When frail, elderly patients who have suffered a health issue such as an infection or a fall no longer need to remain in an acute care hospital, that doesn’t always mean they are ready or able to go home. Yet it can sometimes be challenging to find a smooth way of transitioning them back to the community and preventing hospital readmissions. St. Michael’s has partnered with Toronto Grace Health Centre, Toronto Central Community Care Access Centre and WoodGreen Community Services for Printed on 100 per cent recycled paper
a rehabilitation project aimed to make those transitions more seamless. The project will help frail senior patients receive the supports they need before, during and after discharge, while also freeing up beds in St. Michael’s General Internal Medicine and Acute Care of the Elderly unit. Ontario’s Toronto Central Local Health Integration Network is supporting several projects aimed at rehabilitation for seniors. The programs are known as Assess and Restore. “There was a gap in care for patients in acute care beds that didn’t need
to be there, but who were not yet ready for independent living without rehabilitation,” said Kim Grootveld, case manager for St. Michael’s General Internal Medicine unit. “We’ll evaluate whether Assess and Restore improves the quality of life for our seniors by providing them with a rehabilitation period, social interaction and a plan to help them transition out of hospital and into the community.” Physicians and the geriatric inpatient consultation team assess patients who are between ages 55 and 105 and have Continued on page 7 SEPTEMBER 2016 | IN TOUCH | 1
OPEN MIKE with Beverly Bulmer,
Vice-president, Education
For many in education, September is considered the start of a new year. I, too, feel the shift in gear in the energy of the hospital after Labour Day, but having started my new role on July 1, our portfolio has been hard at work over the summer to bring you a number of exciting updates. New curriculum for disadvantaged patient population We will develop a new curriculum to support the hospital’s strategic priority of advancing systems of care for disadvantaged patients including education opportunities to develop cultural competencies for all our staff, physicians and students. How can we be more sensitive and informed when providing care to our patients who are homeless or vulnerably housed; have serious mental illness or addictions; are from the Aboriginal community; have immigrant or refugee status; or experience disadvantage related to
sexual orientation or gender identity? And what are the best ways for staff and physicians to learn within this context? We’ve begun focus group sessions to hear from not only staff, physicians and students, but also patients and families. We plan to roll out the new curriculum in the new year. Allan Waters Family Simulation Centre strategic planning The Allan Waters Family Simulation Centre is at an important junction in its history. We’ve seen great success with both internal and external clients, accreditation from the Royal College of Physicians and Surgeons and the development of new programs, but the centre is at its capacity. With more than 6,000 users of the centre annually, we must define priorities, explore innovation and map out criteria to make strategic choices between where to grow and where to focus to maximize the future success and sustainability. The team’s 2016-19 strategic plan will help guide its activities and future direction. The centre is more than a place where one can gain technical skills – it’s recognized for its emphasis on enhancing high
performance through interprofessional collaboration and systems evaluation. PSEP offered at St. Michael’s The Canadian Patient Safety Institute’s Patient Safety Education Program is a two-day educational event that certifies members of interprofessional teams as patient safety trainers. Typically, the course is offered at a central location and organizations send participants to it, but St. Michael’s is the first hospital in Canada to offer this course on-site to our staff. We hope this will allow more of our staff to improve patient safety skills, plan patient safety education and support quality improvement initiatives at the hospital. As the first physical therapist to hold the role of vice-president of Education in a Toronto academic institution, I am incredibly excited about leading the Education portfolio, and remain committed to the portfolio’s vision of excellent patient outcomes through leadership in health professional education. I look forward to teaching and learning collaboratively with all of you to continue to advance academic practice across the health system.
Did you know? A synthetic material commonly used to create seamless kitchen countertops, known as solid surface, is also frequently used in health care. Its properties make it ideal for infection prevention and control in clinical spaces such as ORs and ICUs. Being non-porous, it prevents the growth of harmful bacteria and mould. It’s also durable and impact-resistant. In the newly renovated clinics in the hospital’s Donnelly Wing, it’s used to protect corridors and the walls behind handwashing sinks. It can stand up to cleaning products used in health care and can endure frequent bumps from stretchers and wheelchairs. Not only does it prevent holes from forming in walls, where bacteria can then grow, it also keeps clinical spaces clean and fresh. --Kate Manicom SEPTEMBER 2016 | IN TOUCH | 2
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Discharging better informed patients
Paulina Jaros, RN, and Dean Aide review his PODS. She ensures he has a good understanding of his care plan after he is discharged by asking him to repeat the instructions in his own words. (Photo by Yuri Markarov, Medical Media Centre) By Evelyne Jhung
When Verna Duong, a registered nurse on the Trauma and Neurosurgery unit, used to hand her patients their discharge summary, they often stared at it with a look of confusion.
Jaros asks questions such as, “can you tell me when your next appointment is?” and “what medications should you take for your pain and when?”
“The new summaries we have now are much more patient-friendly, with a bigger font size and simpler language,” said Duong.
St. Michael’s has also customized the generic PODS document by working with each service to create service-specific templates and building them into the electronic discharge system. This ensures consistency and makes it easier for residents and nurse practitioners to complete.
Neurosurgery was one of the first two units at St. Michael’s (along with Urology) to pilot the new PODS – patient-oriented discharge summaries. Instead of a summary of their stay in hospital, PODS outlines key information that patients need after being discharged: medications; followup appointments; changes to the patient’s routine; symptoms to watch for and how to respond; and where to get more information. It is a simple care guide that a patient or caregiver can easily follow at home. “Because the summary is easier to understand, patients and their families seem to be more comfortable asking questions after I go over it with them,” said Paulina Jaros, also a Trauma and Neurosurgery nurse. Although other hospitals have piloted PODS, the St. Michael’s approach highlights health literacy best practices, including the use of teach back. That is, staff ask patients to repeat key messages to assess for comprehension.
St. Michael’s is an RNAO Best Practice Spotlight Organization
“When a clinician writes up the discharge summary, the PODS content created for their service is already pre-populated and ready to be tailored to the specific patient being discharged,” said Patrick O’Brien, quality improvement specialist. PODS is a vast improvement from the old discharge summaries, however written tools have limited effectiveness in and of themselves. “The best way to convey this information is to pair the tool with discussion involving the clinician, a patient and their families,” said Katrina Grieve, patient education specialist. “When we engage patients and families with educational material, they become more comfortable asking questions and more confident in taking the next steps in their care journey.”
SEPTEMBER 2016 | IN TOUCH | 3
Pathologist Dr. Eleanor Latta uses her expertise in diagnosing diseases and tissue damage to help develop cases for the new medical curriculum (Photo by Katie Cooper, Medical Media Centre)
Students work together to resolve medical cases in new curriculum By Kaitlyn Patterson
For the first time in more than 20 years, undergraduate medical students entering St. Michael’s FitzGerald Academy will experience a new curriculum – one with more practical, student-led learning than faculty-led lectures.
a patient’s initial visit to her doctor, a diagnosis, followup examinations and treatment. To form a step-by-step approach to this case, Dr. Latta collaborated with a family physician, medical oncologist, radiation oncologist and radiologist.
“When a patient comes to your clinic with a complex problem, there are no lecture notes to rely on,” said Dr. Molly Zirkle, director of the FitzGerald Academy. “The new curriculum helps students apply their newfound medical knowledge to relevant clinical cases and fosters lifelong learning.”
“Medicine is a collaborative effort for both staff and students,” said Dr. Latta. “Working through questions together teaches students to focus a discussion around an issue, to divide work appropriately and then to come up with the best possible course of management for the patient.”
The most significant change in the Foundations Curriculum is the Toronto Patient-Centred Integrated Curriculum, or TOPIC, component. Students work in groups of eight to 10 on a case that integrates material they are learning that week. The online cases involve a narrative of a simulated patient with a real-life clinical problem.
Erica Pascoal, a student from the two pilot programs, found that working through cases as a team helped her understand how to effectively approach a case.
Students are assigned a case on a Monday and work through the case with their group. On Thursday, they meet with a faculty tutor to explain the reasoning behind their answers to case questions and to ensure they have learned important concepts that they can apply to other situations. Dr. Eleanor Latta, a pathologist at St. Michael’s, was a faculty tutor for two pilot programs and will continue this year. She also developed cases for the new curriculum, consulting other health professionals at St. Michael’s to ensure a multidisciplinary approach to each case. For example, a breast cancer case includes SEPTEMBER 2016 | IN TOUCH | 4
“Case-based learning helps us think critically,” said Pascoal. “The questions we have to answer at each step in the case, such as what test needs to be ordered or what type of exam our patient needs, keeps our learning realistic and patient-focused.” The Foundations Curriculum launched in August 2016. Read more about it at www.foundations.md.utoronto.ca
FACT Of the 259 undergraduate medical students from the University of Toronto, 54 attend the St. Michael’s FitzGerald Academy.
Underneath it all By Geoff Koehler
In Dr. Warren Lee’s lab, cholesterol molecules pass through a blood vessel cell and twinkle like stars against the night sky. Some cholesterol flashes brilliantly— shooting stars burning bright and fading just as quickly— while others gradually dim or disappear altogether. Dr. Lee’s is the first lab in the world to see this light show for the purpose of studying how cholesterol or other molecules find their way through the endothelium—the blood vessel wall’s innermost lining. “Until now, it’s been hard for researchers to see how things move through endothelial cells,” said Dr. Lee, a researcher with St. Michael’s Hospital’s Keenan Research Centre for Biomedical Science and a physician in the Medical-Surgical Intensive Care Unit. “Better understanding of how molecules get behind blood vessel cells could one day help researchers reduce cholesterol buildup that causes blocked arteries, improve insulin levels and blood sugar control for those with diabetes, or prevent tissue edema such as occurs during severe lung injury in critically ill patients.” Dr. Lee discovered a new use for a microscope that’s been around since the 1980s. With the microscope, which uses a technique called total internal reflection fluorescence, or TIRF, Dr. Lee can, for the first time, observe cholesterol or other molecules getting transported through endothelial cells in real time. In his lab, Dr. Lee simulated the innermost layer of a blood vessel’s lining by filling a Petri dish with a single layer of endothelial cells. His lab team placed fluorescentdyed molecules, such as cholesterol or insulin, on top of the layer of cells and then focused the TIRF microscope on the bottom of the dish. With the TIRF microscope, researchers could see the bright fluorescent molecules exiting the bottom of the cell. “We’ve used TIRF to study how large molecules, such as LDL (or bad) cholesterol, get out of the blood stream and into other parts of the body,” said Dr. Lee. “In a process called transcytosis, vesicles (a fluid- or air-filled sac) in the endothelial cell act like a taxi for molecules in the blood stream, picking them up and dropping the molecules off on the other side of the blood vessel wall.” With TIRF, Dr. Lee’s lab is able to track several molecules, including insulin, albumin—a protein responsible for swelling during inflammation—and different types of cholesterols, as they’re shuttled through the cell.
Dr. Warren Lee holds a collection of endothelial cell in his Keenan Research Centre for Biomedical Science lab. Dr. Lee has developed a microscope technique that allows scientists to see how molecules such as cholesterol and insulin escape the blood stream and get into other areas of the body. (Photo by Yuri Markarov, Medical Media Centre)
“Our next focus is trying to find ways to stop molecules in the blood stream from hailing the cab,” said Dr. Lee. “For instance, if we can keep cholesterol from getting under the endothelium, we can stop it from building up in the wall of the blood vessel. This could stop the narrowing of arteries that leads to heart disease and stroke.”
Dr. Lee was the lead on a successful $1-million CIHR grant that will bring a TIRF microscope to St. Michael’s Keenan Research Centre for Biomedical Science. Drs. Andras Kapus and Katalin Szaszi will also make use of the microscope to study cells that line other organs, such as epithelial cells in the kidney.
The TIRF microscope will also allow Dr. Lee’s lab to test ways of preventing transcytosis.
SEPTEMBER 2016 | IN TOUCH | 5
Dr. Robert Sargeant (left), head of the Division of General Internal Medicine, discusses the new Rapid Referral Clinic with Dr. David McKinnon, deputy chief of the ED, who calls the new clinic “a great resource.” (Photo by Yuri Markarov, Medical Media Centre)
Having a rapid impact on patients By Leslie Shepherd
A man arrived in the Emergency Department one Friday this summer complaining of shortness of breath and swollen ankles. He had no previous medical history and was a heavy smoker, so staff thought he might have emphysema and prescribed him an inhaler. When that didn’t work, ED staff had two options: Refer the patient to General Internal Medicine for consideration of admission to hospital or refer him to the hospital’s new Rapid Referral Clinic. The choice was obvious. The man was seen in the clinic the following Monday and was also able to snag an open slot in the Echocardiogram Lab, allowing doctors to confirm a diagnosis of congestive heart failure and start him on diuretics. The Rapid Referral Clinic opened in May as a six-month pilot project to provide expedited care within 48 to 72 hours to patients who present in the ED with acute SEPTEMBER 2016 | IN TOUCH | 6
medical problems but who can be managed safely as outpatients, thus avoiding hospital admissions and readmissions. The results so far have exceeded expectations, said Dr. Robert Sargeant, head of the Division of General Internal Medicine, which runs the three-morningsa-week clinic. By early August the clinic had seen 142 different patients over 171 appointments. The average time from ED referral to clinic appointment was 65 hours (2.7 days). Sixtyseven hospital admissions were averted. Follow-up plans were created for all 142 patients and 47 people were referred to subspecialists. The clinic saw the congestive heart failure patient every two days until his symptoms were under control, got him into the hospital’s congestive heart failure clinic, and found him a family doctor in the Family Health Team. Without the Rapid Referral Clinic, Dr. Sargeant estimated
the man would have been admitted to the hospital for four or five days. “Instead, we treated him as an outpatient and he was delighted,” Dr. Sargeant said. Dr. David McKinnon, deputy chief of the ED, called the new clinic “a great resource.” “Most patients prefer to go home and this allows a subset of them to do so safely when they would have been admitted to hospital otherwise,” he said. “In this way, the Rapid Referral Clinic is beneficial for both the patient and the system.” Dr. Sargeant said the Rapid Clinic was needed not just to co-ordinate care of complex patients as outpatients, but also because of changes to the University of Toronto curriculum for residents. As of July 1, residents are required to have more learning opportunities in ambulatory clinics, and the Rapid Referral Clinic provides a teaching venue for senior residents. The clinic is staffed by one physician, one resident and one nurse.
Clinic assesses vision needs of Syrian refugees By Maria Feldman
Dr. Myrna Lichter, an ophthalmologist at St. Michael’s Hospital, and her medical student team have begun a pilot project to assess vision health of Syrian refugees and determine vision needs of this vulnerable population. The first of eight planned pilot clinics was held at the Islamic Institute of Toronto this summer and more than 180 government-sponsored Syrian refugees attended to have their vision screened by volunteer optometrists and ophthalmologists. Following recent work with the homeless population, Dr. Lichter’s team realized there was an urgent need to gather data about the vision care needs of other marginalized groups. “We don’t have any data that clearly looks at the eye care needs of a refugee population in Canada; nothing has been published in the literature about this,” said Tarek Bin Yameen, a secondyear medical student at the University of Toronto, and a refugee himself. “The arrival of 25,000 Syrian refugees and this project represents a unique opportunity for us to close this knowledge gap and finally understand what the eye care needs of a refugee population in Canada are.” One in four of the first screened refugees required followup appointments. In addition, four family members were diagnosed with retinitis pigmentosa, an extremely rare but serious hereditary condition that causes severe vision impairment. “These staggering figures reflect the unique and complex health-care challenges this community faces,” Bin Yameen said. “It’s of utmost importance to us that this vulnerable population receives appropriate followup care.” Dr. Lichter said she hoped that her team could secure $35,000 of additional funding to continue facilitating the study over the coming months.
Tarek Bin Yameen, a second-year medical student at the University of Toronto and co-investigator of the Syrian Newcomer Family Vision Screening Program, prepares for his visit to the pilot clinic. (Photo by Yuri Markarov, Medical Media Centre)
The Syrian Newcomer Family Vision Screening Program is conducted in partnership with Mes Amis, an organization dedicated to assisting Syrian refugees with settlement and assimilation. St. Michael’s Hospital was also one of several health-care facilities in Toronto that participated in the Syrian Refugee Health Network to provide primary care for refugees from December 2015 to May. St. Michael’s Hospital’s Syrian Refugee Clinic saw about 35 patients.
Helping frail senior patients transition story continued from page 1 physical, functional or cognitive decline, such as decreased mobility or dementia. The team assesses these patients on a clinical frailty scale. A one on the scale means the patient is independent; a seven, eight or nine means the patient requires substantial support for daily living. Assess and Restore is for patients who are considered a four to six on the scale. These patients are referred to Toronto Grace, where 10 rehabilitation beds are reserved per month for the program. Patients receive rehabilitation for up to six weeks, while working toward their recovery goals. Before these patients return home, a CCAC care co-ordinator supports their transition by setting up services such as Meals on Wheels to help patients maintain their independence. “This partnership means that CCAC and community partners are involved early, which is instrumental to ensuring our patients get access to the appropriate services we know they deserve,” said
Natalia Zapata, a GIM physiotherapist and coordinator for the partnership involving St. Michael’s. CCAC can also enrol patients in senior-friendly day programs. WoodGreen’s day program runs weekdays from 10 a.m. to 3 p.m., which is helpful for patients whose families are unable to provide care during the day. Programming focuses on physical activity and interaction with other seniors. “Co-ordinating acute care is difficult because we have to balance the flow of patients with quality of care,” said Grootveld. “We’re learning about the most effective way to work with other organizations for this patient population, but hope to see that Assess and Restore can help us strike this balance and empower patients to return home.” The Assess and Restore program has served 20 St. Michael’s patients since it began in November. SEPTEMBER 2016 | IN TOUCH | 7
By Kaitlyn Patterson
Q&A
SHANNON SWIFT CLINICAL NURSE EDUCATOR IN THE MEDICAL-SURGICAL INTENSIVE CARE UNIT.
(Photo by Yuri Markarov, Medical Media Centre). Shannon Swift has a bachelor of science in nursing from Queen’s University and a master of nursing from Ryerson University, which she completed while working as a nurse at St. Michael’s Hospital. She is now a clinical nurse educator in the Medical-Surgical ICU. Q: What is the difference between a nurse and clinical nurse educator? The nursing role is about caring for patients and families every day. A nurse educator’s role includes implementing best practices, identifying product challenges, helping new hires, understanding what’s happening inside and outside the organization and ensuring nurses feel prepared to perform advanced skills. Q: What does a typical day look like? Every day is different, but always includes balancing the immediate needs of the unit with long-term planning for ways to improve the unit for patients, families and staff. In the MSICU, we have huddles twice a week to discuss changes in the unit, new products we’ve received and to address any incidents that have occurred. I always wear a pager and I’ll stay close to the unit on busy days because patient care always comes first.
INTOUCH
SEPTEMBER 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
Q: Why did you decide to transition from nurse to educator? When I was working at the bedside, I would notice challenges that came up frequently and I always wanted to know more about the pathways to resolve these challenges. I became an educator so I could help find solutions and make a difference at St. Michael’s on a larger scale. Q: What is the most rewarding part of your role? Helping nurses find solutions to issues they have identified. When I was reading a quality improvement fellowship book, one thing resonated with me: don’t be a firefighter. This means that you can’t just put the fire out for someone, but you need to provide them with the resources they need to do the task. I engage the nurses in the pathway to resolving an issue and if the first solution doesn’t work, I think it’s important that we try something else together. Q: What do you enjoy doing when you’re not working? I love to travel. I recently got back from a trip to Florida and I’m really looking forward to heading to the Azores islands of Portugal this fall.