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INTOUCHJUNE 2015

Solving the mysteries of heart surgeryBy Geoff Koehler

Dr. Subodh Verma is linking experts around the globe to CARDIOLINK – a collection of researchers working to advance cardiovascular surgery research. (Photo by Katie Cooper, Medical Media Centre)

Cardiovascular surgeon Dr. Subodh Verma was troubled by the lack of data to guide decision making and treatment choices for patients undergoing heart or vascular surgery.

“There are still too many unknowns when it comes to cardiovascular surgery outcomes,” said Dr. Verma. “I think the best way to find those missing links is by connecting smart people and asking smart questions.”

Dr. Verma formed a research hub, called

CARDIOLINK, to answer questions that will improve care and prevent hospitalization for patients with heart and vascular disease or diabetes.

CARDIOLINK brings together top experts from across St. Michael’s, Canada and the world to address five major themes of cardiovascular surgery: atrial fibrillation, aortic aneurysms, peripheral arterial disease, valvular heart disease and community-based interventions to reduce re-hospitalization.

“For each of our five themes, there is a randomized clinical trial being developed

– each designed to address an important gap in cardiovascular research and deliver definitive and potentially practice-changing results,” said Dr. Verma.

The SEARCH-AF trial will investigate whether using a new heart rhythm monitoring device after heart surgery will uncover new rhythm irregularities and help identify individuals at risk of having a stroke following heart surgery. This trial is funded and underway.

The ACE trial is aimed at comparing

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Dr. Michael Freeman Medical Director, Heart and Vascular Program

OPEN MIKE with

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When St. Michael’s decided to conduct an operational review, to look at everything we do with a view to identifying improvement opportunities, the Heart and Vascular Program was among the first to volunteer, along with Perioperative Services and Supply Chain.

A lot of you are probably thinking, “Are you serious, Mike?”

We like to think we’re being proactive and innovative. We see this as an opportunity to find ways to be more efficient, make better use of our resources and improve patient care and professional practice. And if we can increase volumes in the process, so much the better.

Heart and Vascular has gone through several process reviews of our own

recently, in the Cardiac Intensive Care Unit, the Cardiac Catheterization Lab and in Electrophysiology. At the same time, like everyone else, we were being asked to reduce our budget by 1 or 2 per cent every year.

So we welcomed the opportunity to work with consultants Ernst & Young to analyze our data, look at our processes with a fresh set of eyes and identify new opportunities. We will benefit from their extensive experience in implementing changes in other hospitals with values similar to ours and we will learn best practices from them.

We know that implementing change can be hard work. But it’s not rocket science. When you consider that there is no new government money for hospitals, and that government funding is moving away from annual, lump sum funding to activity-based funding tied to volumes and performance, the logical conclusion

is we have to develop innovative, long-term, sustainable solutions.

I’m a physician as well as an administrator and I hear the rumblings that physicians don’t like change. On the contrary. Physicians recognize the need for change. They see inefficiencies in the way we do things. They understand that we have to be on budget and that we can’t spend money we don’t have. They just want to make sure that change results in leading-edge, quality care and improved outcomes for patients, encourages innovation and supports better professional practice.

The St. Michael’s Improvement Program, which is implementing the process redesigns, standardizations and cost savings identified by the Operational Review, will do all of those things. We can’t improve, innovate and transform if we stick to our old ways.

My heart is in this and I hope yours is, too.

Follow St. Michael’s on Twitter: @StMikesHospital

Before 11a.m. discharge (BED) update: Great progress!

In April, In Touch featured a story about local initiatives to help ensure that patients are discharged on time. These activities, plus many more across the hospital, seem to be doing the trick! In April and May, St. Michael’s exceeded our target of 40 per cent and that number continues to climb.

CONGRATULATIONS TO ALL THE UNITS AND BED CHAMPIONS!

By Emily Holton

JUNE 2015 | IN TOUCH | 3St. Michael’s is an RNAO Best Practice Spotlight Organization

As a pediatrician at an inner-city hospital, 30 to 40 per cent of Dr. Tony Barozzino’s patients are immigrants or refugees.

Many of these newcomers face unique health concerns, including infections, chronic diseases and mental health issues, having fled war-torn countries or regions experiencing political strife. Children, especially, experience their own set of challenges, such as poor nutrition and oral care.

Dr. Barozzino, a St. Michael’s pediatrician who has been practising in Toronto for more than 25 years, sees these patients every day.

But many physicians, nurses and nurse practitioners might see them once a month (or much less), which is why the Canadian Pediatric Society and Citizenship and Immigration Canada asked Dr. Barozzino to co-create and co-edit a website with free, up-to-date and accessible information that would help health-care providers best care for immigrant and refugee children and families.

www.KidsNewtoCanada.ca launched in April 2013.

“It’s a resource that’s meant for all clinicians, but particularly those who may not come across immigrant and refugee youth and families as often as we do in the downtown core,” said Dr. Barozzino, who was chief of St. Michael’s Pediatric Department from 2001 to 2012. “Immigrants and refugees typically tend to settle in cities, but that’s not to say health-care professionals across the country – in small and large cities and towns – don’t encounter this at-risk population.”

The website (available in French or English) provides evidence-based information ranging from medical conditions such as malaria and Chagas disease to community resources. It provides guidance to health-care providers about how to be sensitive to differences in patients’ backgrounds. There’s also a section devoted to advocacy for immigrant and refugee health needs.

Say a doctor in Whitehorse had an appointment with a family from Syria – a

Helping providers help kids new to Canada

Le Roi Chijioke Agu, 3, shares a smile with pediatrician Dr. Tony Barozzino. Dr. Barozzino co-edited a new website called Caring for Kids New to Canada. (Photo by Yuri Markarov, Medical Media Centre)

By Melissa Di Costanzo rare occurrence. One of the children, a five-year-old boy, coughed, had a fever and clutched his stomach in pain. The doctor could go to the website and click on these three symptoms (there are 13 listed in total). Up pops a list of results ranging from a roundworm infection to viral gastroenteritis: possibilities for the physician to consider before making a diagnosis, including diseases he or she may not see often in his or her community, such as Dengue fever.

“The website is like a one-stop shop to help ensure these vulnerable children, youth and families receive the best care possible,” said Dr. Barozzino.

It has been incorporated into Canadian medical school curriculums and accessed by people in Australia, Europe and the United States. Although it contains Canada-specific information, Dr. Barozzino said he hoped the website’s scope would continue to spread internationally.

“Across Canada – indeed, across the world – it’s good to have a tool like this to call upon.”

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St. Michael’s protecting elderly patients at risk of harm

Elder abuse is a serious and often unreported health issue. It is estimated that as many as 10 per cent of hospital patients age 65 and over are victims of abuse. For every case that is reported, an estimated 23 cases are not.

Up to 30 per cent of inpatients at St. Michael’s are elderly, with most on the cardiology, medicine and orthopedic units.

“We’ve come up with a multi-pronged approach to raising awareness of elder abuse,” said Marisa Cicero, professional practice and education leader in Social Work. The first step has been to raise awareness of elder abuse with elearning modules, lunch and learn and facilitated sessions. More than 375 staff members have received training.

The social work team also created an elder abuse algorithm, providing tips for working with elderly patients and contact details for resources that are available 24/7.

There has also been a telephone pilot program offering a telephone consultation with a social worker. This service is available Monday to Friday from 8 a.m. to 4 p.m. by calling extension 5090.

“We encourage staff to call,” said Cicero. “No question is too small or insignificant. We’ll do our best to help.”

The World Health Organization defines elder abuse as a “single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.”

Some of the risk factors of elder abuse are poverty, functional impairment and social isolation.

“The things that make you most vulnerable also make it difficult to report,” said Cicero. “There’s also the shame and stigma of being a victim of any type of abuse, but particularly for elder abuse, that makes it difficult. It’s difficult to say I need help in the first place.”

Another complication is that in many cases, the abuser is often the victim’s adult children or spouse, someone the person relies on for support.

The telephone pilot will continue for six months, along with more facilitated training sessions that will be advertised in the Daily Dose or by calling the Social Work office directly.

By Greg Winson

Millie guides users through the elder abuse elearning module.

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Just a few years ago, a typical day in the St. Michael’s Intensive Care Units would begin with the arrival of a team of X-ray technologists. They fanned out across the ICUs with portable machines, and over several hours would carefully reposition and scan each patient one by one. Although several studies show that moving from daily X-rays to ordering X-rays only to answer specific clinical questions does not increase ICU patients’ risk of complications, the practice was – and remains – standard practice in most ICUs.

Dr. Antoine Pronovost, the medical director of the Trauma and Neurosurgery Intensive Care Unit and Dawn-Marie King, the director of Medical Imaging and Laboratory Medicine, saw an opportunity to do things differently. They began a project that reduced the total X-rays ordered in the ICUs by more than 50 per cent. As a result, countless patients have avoided

unnecessary radiation, discomfort and disruption, and only one tech is needed to cover ad-hoc X-rays in the ICUs. The rest of the technologists are now freed up to help support flow in the ED.

To begin, Dr. Pronovost developed a set of new guidelines for portable X-rays in the ICUs, and King worked with her team to explore how an ad-hoc model might work. For example, if a patient developed a fever or his or her breathing changed, he or she would get an X-ray right away to help determine the cause. Medical Imaging committed to being available throughout the day as these situations arose. However if the patient’s status hadn’t changed since the last X-ray, the guidelines said that he or she should go without.

“Change is always challenging,” said King. “Our physicians were concerned that without daily X-rays, complications might get missed. We needed to show them that our guidelines were sound, and having a physician champion to do that was the key.”

Before implementing the guidelines, Dr. Pronovost and his team used them to audit daily X-rays at morning rounds. For

Choosing Wisely: Tackling unnecessary X-rays in the ICUs

Dr. Antoine Pronovost, the medical director of the Trauma and Neurosurgery Intensive Care Unit, reviews a chest X-ray with clinical fellow Dr. Mazin Tuma and nurse practitioner Nikki Marks. (Photo by Yuri Markarov, Medical Media Centre)

By Emily Holton

each image, Dr. Pronovost would ask, “According to the proposed guidelines, would this patient have received an X-ray today? And if not, would we have missed something clinically significant?”

Within a couple of weeks King and Dr. Pronovost had the buy-in they needed. Within a year, all three ICUs had moved successfully to an ad-hoc model. New residents and fellows are briefed on the new practice as they arrive on the units, and staff and physicians reinforce the message.

“It was a great quality improvement project because the end result was less work, not more,” said Dr. Pronovost. “It makes intuitive sense – and is more rewarding – to couple testing with specific clinical questions.”

Since this project began, St. Michael’s volunteered to be an early adopter of Choosing Wisely Canada, a campaign to help physicians and patients make smart decisions about potentially unnecessary tests, treatments and procedures. Learn more at http://www.stmichaelshospital.com/quality/choosing-wisely.php

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Building a senior friendly hospital

As St. Michael’s Hospital builds its new Peter Gilgan Patient Care Tower and renovates large amounts of existing hospital space, it is also taking the opportunity to meet the unique needs of elderly patients and visitors.

St. Michael’s redevelopment project – also known as St. Michael’s 3.0 – will incorporate best practices of senior friendly design based on the Code Plus Senior Friendly Design standards. These evidence-based guidelines take into consideration how well a physical environment is equipped to address the developmental needs of older adults and promote safety, independence and functional well-being for older patients and visitors. However, these improvements will benefit more than just seniors.

“Many of the changes will enhance the comfort and experience of all patients and visitors to the hospital,” said Susan Blacker, co-chair of the Senior Friendly Hospital Strategy. “And they will help our staff, physicians and volunteers to provide the best possible care.”

An important feature being incorporated into the designs is rubber flooring, which has several benefits. First, it is matte. When floors are shiny they can appear to some, particularly those with dementia, as being wet, causing confusion. Second, they are non-slip, which helps to prevent falls for patients and staff. Lastly, they reduce noise and echoes, creating a quieter and calmer environment.

All inpatient rooms in the new tower will have natural light, which has been shown to promote overall health and to reduce falls. Natural light in the tower’s 10-storey Element

Financial Atrium will improve visibility when entering and exiting the building. Maintaining a gradual change in lighting is important in helping to reduce confusion, disorientation and problems with depth perception.

The historic Bond Lobby will be renovated to include an elevator, allowing everyone to use that entrance.

St. Michael’s 3.0 will also see improvements in areas of the hospital that see high levels of older patients, such as cardiology and orthopedic inpatient units. While the current orthopedic inpatient unit, situated

on 4 Bond, has narrow hallways that are obstructed by equipment, its future home on the ninth floor of the new tower will be more spacious.

“Wider corridors, larger patient rooms and fully accessible washrooms will help all orthopedics patients recovering from hip, knee, spine, shoulder and ankle operations to navigate the hospital,” said Valerie Audette, the unit’s clinical leader/manager. “The unit will also have bigger storage areas, reducing clutter in the hallways and helping patients and staff to get around.”

Ample handrails, natural light and wide corridors are design elements that will be incorporated into the plans for St. Michael’s redevelopment project. (Rendering by NORR)

By Kate Manicom

IMPLEMENTING SIMPLE CHANGES CAN IMPROVE HOSPITAL ENVIRONMENTS FOR SENIORS:

• Install seating in long hallways and next to elevators

• Use a matte, non-glare finish on floors

• Paint handrails a colour that contrasts with floors and walls

• Ensure signage is uncluttered and language is consistent; avoid technical or medical language and jargon

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strategies to protect the brain when surgeons need to cool the body and stop blood circulation during complex aortic surgery. Dr. Verma said brain protection is the Achilles’ heel of aortic surgery and ACE will help answer whether a new technique—developed at St. Michael’s—is safe for patients undergoing these operations.

Critical limb ischemia is a serious

CARDIOLINK story continued from page 1 problem that affects patients with peripheral arterial disease. It carries a high risk of limb amputation and a 50 per cent chance of dying within five years. CARDIOLINK has developed the EXTINGUISH trial to test whether an anti-inflammatory medication can reduce rates of death in patients with critical limb ischemia.

The CAMARA-1 trial will compare two different ways to repair the mitral valve to see whether one is better at

By Roshni Jayawardena

When people consider the impact Canada’s aging population will have on society, they may focus on pension plans or perhaps strains on the health care system. Dr. Tom Schweizer thinks about cars.

“Doctors are asked to identify elderly patients who may not be fit to keep driving, but physicians don’t have the tools to determine when it is really time to take away the keys,” said Dr. Schweizer, director of the Neuroscience Research Program of St. Michael’s Hospital. “At a certain point, aging can hinder driving ability and safety; the trick is knowing when.”

The Ministry of Transportation has awarded Dr. Schweizer’s team $72,286.00 to evaluate Ontario’s senior driver’s license renewal program and answer that question.

Once a driver turns 80, he or she is required to successfully complete the renewal program every two years to keep his or her license. The test is comprised of a vision test, driving record review, group education sessions, two written exercises and, if necessary, a road test.

The study will include 40 patients. Using a functional MRI, Dr. Schweizer will study which areas of the brain are

active during simulated driving and during written tests completed on a tablet.

Testing under an MRI requires sophisticated technology that can work safely under high-powered magnets. The tablet and driving simulator–equipped with a steering wheel, brake pedal and accelerator–are one-of-a-kind and were developed specifically for Dr. Schweizer’s research.

“We want to determine whether the ministry’s mandatory tests challenge the same parts of the brain people actually use when driving,” said Dr. Schweizer. “If the tests aren’t relevant to safe driving, we hope to develop tests or tools that are more effective.”

improving the functional capacity of patients and restoring them to more meaningful lives.

The ENABLE-NP study will try to find better ways to meet the complex needs of vulnerable patients by engaging their communities. It will evaluate whether interventions delivered by nurse practitioners in the community can reduce rates of re-hospitalizations after peripheral artery surgery.

When to stop driving, the age-old question

Q & ALee Ringer is the clinical nurse specialist for seniors, or, as she notes, “I’m a senior caring for other seniors.”

Q. Tell us about your role.

It’s a multifaceted role involving clinical assessments, education, research, advocacy and leadership. I see frail elders throughout the hospital for comprehensive geriatric assessments. We see all new patients with fragility fractures and all new geriatric trauma patients in the TNICU. The only unit where we don’t see patients is maternity. I advocate for compassionate person-centered care of the frail elderly. A lot of my work involves educating families and caregivers and linking them with resources.

Q. What does your average day look like?

I start around 8 a.m., reviewing new consultations for the day. I follow up and problem-solve with inpatients, for such things as their health status and behaviours of concern that may be challenging. I work on the senior friendly hospital strategy and I do a lot of education and a great deal of public speaking throughout the hospital on topics such as

LEE RINGER, CLINICAL NURSE SPECIALIST FOR SENIORS

responsive behaviours or the difference between dementia and delirium.

Q. How is the aging population changing health care?

We’re seeing a tsunami of older people as the baby boomers get older. People are living longer so they are living with more co-morbidities and chronic diseases. Falls are a big issue, as well as polypharmacy – taking too many medications – dementia and delirium.

Q. Tell us about your special interest in dementia?

In my previous position I worked with people with responsive behaviours in long-term care facilities. When I came to my present position, I identified learning needs for the frontline staff to manage responsive behaviours in acute care. I started to do research and education and working on committees to bring in training for people living with dementia and delirium.

Q. Getting old is hard. It is also a triumph. Can you tell us a senior who is a role model for all of us?

Hillary Clinton. At the age of 67, when she could be thinking about retirement, she’s planning a new career as candidate for president of the United States.

By Leslie Shepherd

(Photo by Yuri Markarov, Medical Media Centre)

INTOUCH JUNE 2015

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 Dermot Covel, Medical Media Centre

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