Printed on 100 per cent recycled paper APRIL 2015 | IN TOUCH | 1

Going upstream to improve healthBy Geoff Koehler

Dr. Gary Bloch says the first stop a patient makes after receiving a prescription doesn’t always have to be the pharmacy. (Photo by Katie Cooper, Medical Media Centre)

St. Michael’s has established a committee dedicated to addressing the social determinants of health, the first family health team in Canada to do so.

Social factors such as income, education and employment status, play pivotal roles in a person’s health and well-being. These factors, known collectively as the social determinants of health, have been shown to particularly affect the health of inner city populations.

“Every day in clinic we saw the effect social determinants of health had on our most vulnerable patients and knew we had to do something to change the status quo,” said Dr. Gary Bloch, a family physician and

chair of the Social Determinants of Health Committee in the Department of Family and Community Medicine.

The committee oversees several projects targeting root causes of health inequity.

The Family Health Team has a dedicated health promoter, Karen Tomlinson, focused on improving income security for patients living in poverty. The IGNITE (addressInG iNcome securITy in primary carE), randomized controlled trial will evaluate this position.

Legal Aid Ontario funded a lawyer, employed by the ARCH Disability Law Centre, to work at St. Michael’s 80 Bond St. clinic. The lawyer, Johanna Macdonald, works closely

Since the hospital renewed its focus on “before 11 a.m. discharge” (or B.E.D. if you’re in the know) in 2014, several units and programs have found new ways to get patients ready to go home sooner. The results have been remarkable.

The impact of an earlier discharge – by just a few hours – is surprisingly great. Emergency Department volumes peak around 1 p.m., so having a few more free beds on the wards after lunch can prevent major bottlenecks for E.D. patients waiting to be admitted.

The Hematology/Oncology Unit has

By Emily Holton

Continued on page 7 Continued on page 6

INTOUCHAPRIL 2015

Before 11 a.m. discharge: These units know what time it is

APRIL 2015 | IN TOUCH | 2

This month, we launch our annual blueprint for improving the quality and safety at St. Michael’s Hospital: the 2015-16 Quality Improvement Plan.

Continuous quality improvement – the ongoing pursuit of doing things better – is a commitment that leadership, physicians and staff across St. Michael’s make for our patients each and every day. Every year, we refresh the QIP to make sure that our efforts will bring us closer to our collective goal: the best possible experience for all patients, at all times.

Building on our successes and learnings from last year, the hospital is focusing on quality improvement in four main areas in 2015-16:

Better handwashing. It’s our job to protect our patients from hospital-acquired infection. To improve St. Michael’s “Moment 1” compliance rate (washing hands prior to contact with a patient or the patient environment) we’ll focus on staff education, increased audits and on-the-spot feedback across the

Doug Sinclair Executive Vice-President and Chief Medical Officer

hospital, and improvements to workflow in the ICUs. Improving our handwashing performance continues to be a long journey, but we are making progress. St. Michael’s stretch target for this year is to reach 65 per cent compliance.

Right medication. Medication reconciliation is a formal process in which the hospital works with patients, families and care providers in the community to make sure all parties have the patient’s correct medication information. Our goal in 2015-16 is to provide and document the medication reconciliation process on admission 80 per cent of the time in our Mental Health and Addictions Program. We’ll get there by using and further testing the electronic medication reconciliation tool that worked well in the cardiovascular service last year.

Fewer falls. To a patient, a bad fall in hospital can mean the difference between going home to recover, and a longer stay with a myriad of complications. St. Michael’s goal this year is to reduce the number of patient falls at St. Michael’s to a rate of 4.09 falls per 1,000 patient days. This year, our refreshed Falls Prevention Program will include a better process for

OPEN MIKE with

reviewing and debriefing after a patient falls, to make sure lessons learned are documented and put into action.

More efficient discharges. On almost any given day, some of our patients will wait more than 18 hours in our ED before they can be admitted to our units. These waits are uncomfortable, frustrating and undermine our quality of care. To speed up these transitions to the units, we need more efficient, more coordinated discharges from the units. There is lots of work to do this year. For example, a new initiative to better identify and continually update patients’ expected dates of discharge will improve hospital-wide planning and as a result, improve bed empty time across the hospital. St. Michael’s goal is to improve or maintain our performance on discharge patient satisfaction; Emergency Department length of stay for admitted patients; discharge summary completion and 30-day readmission rates.

Along with all Ontario hospitals, we post our annual QIP publicly and share it with the province. I invite you to visit www.stmichaelshospital.com/qip to check out the plan.

Follow St. Michael’s on Twitter: @StMikesHospital

• St. Michael’s full- and part-time staff have access to the Employee and Family Assistance Program

• The program provides accessible, confidential and immediate support for a range of issues such as:

• Workplace challenges • Lifestyle / wellness• Conflict • Achieving well-being• Harassment • Improving nutrition• Bullying • Focusing on your health

Did you know?

Employee and Family Assistance Program

http://www.shepell.com/en-ca/totalhealthsolutions/yourefap/

Call 1-877-890-9052 24 hours a day seven days a week

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

Forty per cent of lower back pain in active young people is related to non-herniated discs. Surgery isn’t an option for many of them and physiotherapy only eases the symptoms, forcing them to give up a lot of physical activity during some of the most productive years of their lives.

Some physicians have been using a minimally invasive treatment called intradiscal biacuplasty to treat this “discogenic” pain that originates in the spinal discs that act as cushions between the vertebrae.

Dr. Michael Gofeld, an anesthesiologist with expertise in chronic pain management, recently treated an 18-year-old woman who had debilitating back pain for four years, making St. Michael’s the first hospital in Ontario to use this procedure.

During the procedure, two probes are inserted through a needle with X-ray guidance into either side of the affected

disc. High-energy radio waves are then passed through the tips of the probes, causing molecules to move rapidly and gently warm up. The probes are cooled internally by sterile water, which dissipates the heat around the needle. Tissue is destroyed but no residue is left behind, so the probe’s reach is greater and the procedure can destroy larger areas of tissue.

The procedure may close small tears and fissures associated with disc pain and destroy pain-transmitting nerves inside the disc. The procedure is done on an outpatient basis, takes only about 45 minutes, and the patient requires only light sedation and local anesthesia. Similar equipment has been used for liver and lung tumour ablations.

A hot (and cold) new concept in pain management

Dr. Michael Gofeld is a chronic pain management specialist and an anesthesiologist at St. Michael’s. (Photo by Yuri Markarov, Medical Media Centre)

By Leslie Shepherd

A multicentre clinical study in which Dr. Gofeld participated as the senior investigator has just been completed and demonstrated significant and lasting benefits, such as reduction of pain and disability and improvement in quality of life. A followup study demonstrating cost-effectiveness of this method is in preparation.

Dr. Gofeld is also using radiofrequency ablation to treat pain associated with cancer that has spread to bones. By using probes cooled by water, the same size needle with cooled probes can destroy a lesion eight times bigger than one that is not. While the procedure can reduce the size of tumour, effectively slow progression of metastases and alleviate pain, it is not a cure.

A FEW FACTS ABOUT PAIN

• 60-90 per cent of Canadians will experience lower back pain at some point.

• Chronic pain costs Canadians $10 billion annually.

APRIL 2015 | IN TOUCH | 4

At St. Michael’s, we closely watch how long patients that get admitted wait in the ED, because that wait can be so difficult for patients. Imagine if you or someone you love has ended up in the ED and is sick enough to be admitted. Although you may be very tired and in pain, you are forced to remain on a stretcher, sometimes in a hallway or very busy area, for hour after hour while the hospital struggles to find you a bed.

All hospitals are required to track and report their performance on ED length of stay as part of their annual Quality Improvement Plans for the province. St. Michael’s goal for this year is to have nine out of 10 admitted ED patients wait no more than 21 hours between registering in the ED and moving on to an inpatient bed. Our latest numbers show that at St. Michael’s, nine out of 10 patients wait a maximum of 24.6 hours, so there is more work to do.

Every night at 11:30 p.m. and morning at 7:30 a.m., the director of hospital operations on duty sends an update to hospital leadership on what’s happened overnight.

Here’s a look at an average Tuesday night in February – a steady night for the inpatient areas and the Emergency Department. The main challenge was finding beds on the units for patients admitted from the ED. Several patients had to wait for many hours in the ED for a bed while units upstairs worked together to try to make space. Thankfully, there were no security concerns or emergency codes that night.

St. Michael’s After Dark

The ED evening/night shift overall

Between 3:30 p.m. on Feb. 24 and 7 a.m. on Feb. 25, 85 new patients arrived in the ED. That’s 73 arrivals before midnight and then 12 more between midnight and 7 a.m.

At one point in the evening, there were more than 70 patients in the ED.

85 ED PATIENTS TOTAL

WORKING AT CAPACITY

We went into the night with no capacity to admit patients in the medical cluster. This means that several patients remained in the ED overnight because the units couldn’t take them. To help out, the Medical-Surgical ICU gave one of its beds to a medical patient, even though she didn’t need intensive care.

By Emily Holton and Dermot Covel

6 ADMITTED PATIENTS WAITED IN THE ED MORE THAN 18 HOURS BEFORE THEY COULD MOVE TO AN INPATIENT BED

43 PATIENTS ADMITTED TO HOSPITAL35 BEFORE MIDNIGHT8 BETWEEN MIDNIGHT AND 7 A.M.

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ED snapshot at 11 p.m.47 PATIENTS IN THE ED

12 PATIENTS ADMITTED AND WAITING TO BE ASSIGNED AN INPATIENT BED

8 WAITING FOR BEDS IN GENERAL INTERNAL MEDICINE

1 WAITING FOR A BED IN NEUROSURGERY

3 WAITING FOR BEDS IN MENTAL HEALTH &

ADDICTIONS PROGRAM

ISOLATION CHALLENGES

Eight of the 12 patients waiting for an inpatient bed

needed to be isolated, to protect them or others from

infection and/or viruses. Because isolation patients

can’t share rooms, these cases can compound pressures

on patient flow. For example, the Cardiovascular Unit

had to close several beds that night to turn shared

rooms into single isolation rooms. Cardiac Surgery took on four cardiovascular patients to help out.

That night, several mental health beds were closed due to a flood. The director of hospital operations asked Toronto Police Services and Toronto Paramedic Services to reroute psychiatry patients to other hospitals wherever possible. Both services agreed to do so.

FLOOD ON THE 17th FLOOR

ED snapshot at 7 a.m.24 PATIENTS IN THE ED

16 PATIENTS ADMITTED AND WAITING TO BE ASSIGNED AN INPATIENT BED

READY FOR THE DAY AHEAD

On Feb. 25, the Operating Room began the day open to external referrals, which means we had enough room in the schedule to accommodate elective surgeries as well as our urgent cases (such as trauma surgeries). Although there were very few available inpatient beds that morning, medical discharges were expected later in the day. The director of hospital operations decided that we could manage the day without issuing a bed alert status.

APRIL 2015 | IN TOUCH | 6

improved its B.E.D. by more than ten per cent in just a few months. Case manager Barb Hooper attributes that success to physicians and staff championing the right recipe of tools and initiatives, including one to make sure patients have a ride home arranged ahead of time.

An audit of late discharges showed Hooper that rides home were a big issue; patients and families needed help planning ahead. Hooper introduced a laminated sign to be posted beside every bed in the unit, with the patient’s estimated date of discharge and a reminder to arrange a pickup for 10:30 a.m. that day. She feels it’s really helped.

“Now, we can identify and address barriers and concerns about going home ahead of time,” said Hooper. “We’re having fewer conversations on the day of discharge.”

The General Surgery, Gastrointestinal and Plastics Units have tackled the same issue. The units’ physicians start

the conversation with patients about their date of discharge and ride home, and the staff reinforce those messages for patients throughout their stay. Up to 75 per cent of patients in General Surgery are now discharged before 11 a.m.

Both Hooper and Joanne Bennett, the clinical leader-manager for General Surgery, Gastrointestinal and Plastics, say that weekly performance data from the hospital’s Decision Support team has helped inspire their teams. Hematology/Oncology post their progress over time on a graph posted in their report room, and the team reviews the numbers together at huddles and at inter-disciplinary rounds. In General Surgery, B.E.D. data is a weekly agenda item at all staff and surgeons’ meetings.

“We take pride in our B.E.D. performance,” said Bennett. “No one wants to see those numbers go down.”

The Cardiovascular Unit has boosted its B.E.D. performance from 19 per cent in the fall to about 50 per cent today. They began with a brainstorming session,

Discharge story continued from page 1 when the multidisciplinary team listed their unit’s barriers to B.E.D. Some solutions were simple, such as making sure the patients’ discharge papers were in their charts the night before. Some required more investigation and evaluation, such as a new approach to the medication schedules that patients take home with them.

Cardiovascular surgery nurse practitioner Marnee Wilson re-evaluated her own practice, and how her decisions can affect a patient’s discharge time. Every day, Wilson reviews her patients’ estimated dates of discharge.

“I go down the list and think, what do I have to do before we can get this person home,” said Wilson. “Have I completed the discharge summary, what tests do I need to order, does this patient need a physio assessment or education around medications before they can leave? I can make sure those visits are arranged ahead of time.”

Beside every bed in Hematology/Oncology is a laminated sign with the patient’s estimated date of discharge and a note reminding them to arrange a ride home. (Photo by Katie Cooper, Medical Media Centre)

APRIL 2015 | IN TOUCH | 7

Dr. Peter Vadas, an allergist and immunologist at St. Michael’s Hospital, reviews his notes before a patient consultation via telemedicine. (Photo by Yuri Markarov, Medical Media Centre)

Accessing specialized care at St. Michael’s Hospital has never been easier. Through the hospital’s telemedicine program, close to 120 clinicians from 50 specialty programs such as cardiology, respirology (cystic fibrosis), nephrology and neurology have used telemedicine to care for patients without them having to leave their communities.

Most recently Drs. Najma Ahmed, Joao De Rezende-Neto, Bernard Lawless, John Marshall, Ori Rotstein and Sandro Rizoli, physicians from the trauma and acute-care surgery team, began holding

trauma telemedicine followup clinics for patients primarily treated for abdominal or thoracic injuries.

This clinic was created to eliminate the barrier to followup care that some patients face given the great distances they have to travel to return to St. Michael’s.

Now these patients are connected to one of the trauma physicians, a nurse practitioner and resident via telemedicine. A nurse is present with the patient and is responsible for checking his or her vital signs and controlling the camera so the team at St. Michael’s, gathered in the telemedicine studio in the Shuter wing,

has a clear view of the wound.

“In addition to monitoring a patient’s physical recovery, our trauma telemedicine clinics also provide an opportunity to check how patients are recovering socially and emotionally,” said Kirsty Nixon, a nurse practitioner on the trauma and acute-care surgery team.

“These are often harder elements to visualize than a wound. Having the ability to interact with ease via telemedicine makes these consultations just as valuable as in-person visits and helps us assess any struggles they may have around returning to everyday life, such as returning to work or school.”

Telemedicine has been used at St. Michael’s since 2004. Dr. Paul O’Connor, director of the Multiple Sclerosis Clinic, was the first physician to hold a one-on-one clinical consultation via telemedicine in April 2005. Dr. Peter Vadas was the first physician to provide allergy and immunology care for patients from Moosenee and Moose Factory, approximately 850 kilometers north of Toronto.

Both physicians remain active users of the technology.

“St. Michael’s is well known for caring for the disadvantaged and vulnerable in the community near the hospital, but telemedicine has allowed us to extend our community up to northern Ontario,” said Dr. Vadas. “Geography is no longer a barrier for these patients. With the click of a button I can see and interact with them on my computer from their community’s telemedicine location.”

By Heather Brown

Telemedicine program at St. Michael’s eliminating barriers to care

with community partners to address legal needs affecting patient health outcomes, such as employment or housing disputes.

To improve literacy, Family Health Team clinicians encourage parents to read aloud to their kids. A joint initiative with the Toronto Public Library called Reach out and Read makes age-appropriate books available for free to kids during checkups.

The result of such diverse projects is

Social determinants story continued from page 1 a multidisciplinary practice unlike any other doctor’s office.

“Patients are surprised to be handed a children’s book or referred to someone in the clinic who can help them with their taxes, but they’re pleasantly surprised,” said Dr. Bloch.

These interventions are only the first part of the committee’s plan to improve health outcomes for St. Michael’s inner city patients.

“These interventions likely make a difference for our patients but we need

to quantify that,” said Dr. Andrew Pinto, a family physician and scientist at the Li Ka Shing Knowledge Institute. “As an academic centre, we study each project to find out what works and what can be improved.”

As the committee’s lead researcher for these projects, Dr. Pinto said he hopes that such evidence will encourage other institutions with similarly vulnerable patients to develop their own social determinants of health committees, try novel interventions and challenge the status quo.

Q & AInez McKenzie worked as a registered nurse on the Labour and Delivery Unit for 28 years before returning as a volunteer 16 years ago. She has led more than 700 pre-natal tours for expectant mothers and their partners.

Q. Tell us about your role.

My main responsibility is to lead the pre-natal tour on 15 Cardinal Carter on Tuesday afternoons. The tour runs from 1 to 2 p.m. each week and provides new mothers and their partners with the opportunity to learn more about what to expect when they come to deliver their baby. They see various spots on the Labour and Delivery Unit such as the triage room, a labour room, the Neonatal Intensive Care Unit and a post-partum patient room.

Q. Do you have any memorable moments from the tour?

Recently I had a couple who showed up at the end of one of my tours because they were delayed in getting to the hospital. I explained that the tour had ended but that there were other tours they could participate in later in the week. The expectant mom looked at me and said “is there any way you could show us around? Our baby is due tomorrow and we’ve never been through anything like this before.” I of course couldn’t refuse so I gave them their own private tour so they felt prepared for the next day.

INEZ MCKENZIE, VOLUNTEER AT ST. MICHAEL’S HOSPITAL

Q. What is the most rewarding thing about volunteering at St. Michael’s?

The first is sharing in the family’s excitement as they enter this last milestone of their pregnancy. Coming for a pre-natal tour means their big day is almost here. Being there to answer their questions is special to me. I also really like working with patients who are new to Canada and have little to no experience with what it’s like to give birth in a hospital here. For instance, many new immigrants are surprised to hear they don’t have to pay for their medical care or food when they are in the hospital.

Q. What are some of the common questions you are asked during the tour?

There are a few:• When should I come to the hospital?• How long will I stay?• Can my children and husband stay with me?• What are the visiting hours and how many visitors can I

have in my room?• Do I need a car seat to take my baby home? What if I don’t

have a car, do I still need one?

Q. What is the strangest question anyone has asked on the tour?

The one question that stands out in my mind was “is there an emergency elevator that I can take right to the 15th floor so that I don’t have to wait for the elevator when I’m in labour?”

By Heather Brown

(Photo by Katie Cooper, Medical Media Centre)

INTOUCH APRIL 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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