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

INTOUCHFEBRUARY 2015

Call me maybe? One step closer to homeBy Emily Holton

Tony, a patient in Trauma/Neurosurgery practices using the call bell with Sarah Wallace, a recreation therapist. Tony underwent the training while recovering from two back-to-back brain surgeries. After the training, he graduated to a rehab facility within days. (Photo by Katie Cooper, Medical Media Centre)

“If you need help, push this button.” For some patients with traumatic or acquired brain injury, learning to follow these simple instructions can mean the difference between weeks of hospitalization and moving on to the next stage of their recovery.

In the Trauma/Neurosurgery Unit, patients who are at high risk of falling or wandering away from their beds stay in “high observation” rooms. For their own safety, these patients are watched by clinical assistants 24 hours a day, seven days a week.

Until recently, once a patient was under high observation, there were no standard criteria to help the interprofessional team decide when he or she was safe to transfer out. Without clear guidelines, patients’ transitions to rehab or long-term care were often delayed; rehab and long-term care facilities won’t accept patients straight out of constant care.

The team got together to develop its own criteria and came up with a simple solution. If a patient under high observation could demonstrate that he or she consistently used the call bell to ask for help, the team could feel confident that patient wouldn’t try to get

up alone and risk a fall.

To begin, occupational therapist Shari Vanderhoek developed a set of repetitive questions for patients, guided by OT principals of cognitive retraining, to reinforce the use of the call bell. Additional members of the Trauma/Neurosurgery team including a case manager, physiotherapist, recreation therapist and nurses worked together to create guidelines to help identify patients who were good candidates for the training. Once eligible patients demonstrate that they can use the call bell consistently and effectively for 24-72

Continued on page 7

Vas Georgiou Executive Vice-President and Chief Administrative Officer

OPEN MIKE with

FEBRUARY 2015 | IN TOUCH | 2

…And we’re off! You’ve heard a lot about the St. Michael’s 3.0 redevelopment project over the past three years. We’ve shared our goals, our design plans and the improvements that the project will bring. Now the contract has been signed and the time has come to start building. I’m excited that Bondfield Construction was awarded the design-build contract and, as I’m sure you’ve seen, has already begun work on site. In this first phase of construction we’ll see the upper floors of the Donnelly Wing renovated while the site at Queen and Victoria is excavated and construction of the Peter Gilgan Patient Care Tower begins.

We know the team at Bondfield well: the company built the five-storey addition

to our Cardinal Carter wing in 2002, and did so on time and on budget while the hospital remained fully operational. Out of all of the bidders for our renewal project, Bondfield’s proposal offered the shortest timeline, with a completion date for the patient care tower of 2018. The company has an extensive portfolio in health care, education and commercial projects, and we’re confident it has the skills and experience to make our vision for St. Michael’s 3.0 a reality.

Now you may be asking, how will this project affect me and my day-to-day work? Unfortunately, a change like this doesn’t come easily. If you’ve ever done any home renovations, you know that with growth comes growing pains. Noise, vibrations and other disruptions will certainly affect us and how we do our jobs in the coming years. We, along with Bondfield Construction, will do our

best to alleviate these interferences. And, I’m hoping we can work together to help alleviate any challenges for our patients.

And even though building has started, our conversation about St. Michael’s 3.0 doesn’t stop. We’re committed to giving you regular updates on construction and telling you how it will affect you through Daily Dose, the intranet and other channels. And if you have questions for us, we’ve set up a dedicated email, BuildingSMH@smh.ca, where you can voice your concerns.

This is an amazing time for St. Michael’s Hospital. The Peter Gilgan Patient Care Tower, the expansion of the Slaight Family Emergency Department and the suite of other improvements we’re making throughout our hospital have us poised to provide the best care in Canada for critically ill patients. I hope you are as excited as I am.

Follow St. Michael’s on Twitter: @StMikesHospital

St. Michael’s Milestones

15 FIFTEEN YEARS AGO

• The Wellesley Hospital joined with St. Michael’s Hospital

• Surgeons at St. Michael’s performed Ontario’s first live-donor kidney retrieval using minimally invasive surgery

• St. Michael’s became one of the first employers in Canada to create a formal mentorship program designed exclusively for recent immigrants

50 FIFTY YEARS AGO

• The gift shop opened

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

Maggie Atkinson, a lawyer and long-time HIV survivor, was shocked to realize that her father had better brain function at age 80 than she did at 45. Finding words was one of many problems that made conversations so embarrassing that she started to withdraw from social events.

“It got so that I couldn’t even remember friends’ names or everyday words like toaster,” said Atkinson.

Such symptoms, along with a shortened attention span, difficulty with short-term memory and reduced efficiency with solving problems, are typical of HIV-associated neurocognitive disorder, or HAND, a condition similar to a mild form of dementia that occurs when HIV enters the nervous system and can progress at a very slow rate.

“My parents weren’t having the same problems I had, so I knew it wasn’t just accelerated aging,” said Atkinson. “I was definitely experiencing brain damage from the HIV.”

That was before she started the Brain Fitness program, a version of which is run by Dr. Sean Rourke, a scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital.

In the program, patients improve their cognitive ability by playing progressively challenging games on the popular Brain HQ app and website that test their memory, processing speed and problem solving skills. A quick game might have patients race against the clock while

sifting through a word list for synonyms. They do about 30 minutes a day for 10 weeks.

“Since [HAND] is not a complete breakdown of the brain, it can be retrained,” said Dr. Rourke. The Brain Fitness program “is physiotherapy for the brain.”

During the past five years, Dr. Rourke treated about 50 people with HAND and has “a pile of data that shows it works for some people.”

Human brains have a lot of redundancy and 95 per cent of what they do each day is routine, said Dr. Rourke. But if people activate the brain in a different way, they can stimulate or create new pathways.

Atkinson is living proof.

“The Brain Fitness program was a real life-line for me,” she said. “It was

amazing how the words just came back. It’s like the program turned the clock back by a decade.”

To prevent the improvements from tailing off, Dr. Rourke found patients had to keep at it. He said the brain is not unlike a muscle that tightens up when

What’s good for the heart is good for the brainBy James Wysotski

not exercised regularly.

His next step is to show how actual physical exercise assists those doing Brain HQ.

“What’s good for the heart is also good for the brain,” is Dr. Rourke’s credo. He said that if HIV positive people exercise, they’re half as likely to have cognitive impairment.

Since taking the program, Dr. Rourke’s patients have become more socially and physically active. It builds their confidence and self-esteem. And since cognitive status and activity levels go

hand in hand, the challenges of social interactions help the healing.

“All these things have additive effects to what you do to keep your brain healthy,” said Dr. Rourke.

“I was only expecting people to feel better, but in fact they don’t just feel better and have less symptoms, they also did better on [our assessment] tests,” said Dr. Rourke.

Maggie Atkinson does Brain HQ challenges on her iPad. (Photo by Yuri Markarov, Medical Media Centre)

FEBRUARY 2015 | IN TOUCH | 4

Fast-tracking concussion care

Traumatic brain injury is likely to become one of the biggest public health problems by 2020, according to the World Health Organization.

But patients who come to the Emergency Department at St. Michael’s Hospital with mild TBI are often unsure of their next steps after diagnosis. They face a long wait list to see a specialist and struggle to find appropriate support to manage persistent symptoms such as headaches, dizziness or difficulty concentrating after they go home.

“We were seeing patients who’d made more than 30 hospital visits because

By Kate Manicom their symptoms never improved,” said Dr. Donna Ouchterlony, who leads St. Michael’s Head Injury Clinic. “We clearly needed to change our system to give more support to these patients.”

The hospital recently created the Urgent Care Concussion Clinic to fill the gap for patients between leaving the ED and visiting their family doctor or a specialist, where it can take several weeks to get an appointment.

Now, when a St. Michael’s patient is diagnosed with a mild TBI or concussion, he or she can be referred to the Urgent Care Concussion Clinic. Before discharge, referred patients receive an education booklet about their condition and are told that someone will

call to follow up within five days.

During the followup phone call, a clinical nurse specialist uses a comprehensive questionnaire to determine the need for rapid referral. Patients with milder symptoms are directed to their family physician, those with acute symptoms are seen in the Urgent Care Concussion Clinic for short-term care, while those with more severe symptoms are sent to the Head Injury Clinic.

“We’ve brought in social workers to assess the psychological needs of patients and to provide support for them and their families. And we developed the education booklet,” said Dr. Ouchterlony. “Our goal is to standardize guidelines for brain injury assessments and try to get everyone – military, sports and rehab physicians and family docs – on the same page in terms of assessing and treating traumatic brain injuries.”

According to Dr. Chantal Vaidyanath, a physiatrist, or rehabilitation physician, at the clinic, the prolonged symptoms of mild TBI can be challenging for patients.

“They fear they won’t be able to work, they can’t sleep and the continuation of these problems can result in depression,” said Dr. Vaidyanath. “That’s why it’s so important that we find ways to treat the symptoms and help patients feel like themselves again as quickly as possible.”

According to Dr. Ouchterlony, the Head Injury Clinic still has a long wait list, but the Urgent Care Concussion Clinic’s fast-tracking improvements and new research should help TBI patients to improve their quality of life.

Dr. Chantal Vaidyanath, a physiatrist with St. Michael’s Head Injury Clinic, meets with patient Todd Sharman about his progress. (Photo by Yuri Markarov, Medical Media Centre)

COMMON SYMPTOMS OF A MILD TRAUMATIC BRAIN INJURY

Physical Behavioural/Emotional Cognitive

• Headache• Nausea• Vomiting• Blurred or double vision• Seeing stars or lights• Balance problems• Dizziness• Sensitivity to light or noise• Tinnitus

• Drowsiness• Fatigue/lethargy• Irritability• Depression• Anxiety• Sleeping more than usual• Difficulty falling asleep

• Feeling “slowed down”• Feeling “in a fog” or “dazed”• Difficulty concentrating• Difficulty remembering

FEBRUARY 2015 | IN TOUCH | 5

Newer than newBy Geoff Koehler

When Keith Adams came to St. Michael’s Hospital, he’d already suffered one heart attack and knew his faulty heart valve was in desperate need of repair.

His referring physician told Adams to expect a new treatment, called MitraClip, which has been available in Ontario for only 18 months. However, Adams’s cardiologist, Dr. Neil Fam, saw him as a perfect candidate for an even newer procedure, Edwards’ transcatheter mitral valve replacement. Adams became the first patient in North America treated with this device and only the fifth in the world.

“Mitral regurgitation, which Adams suffered from, occurs when the mitral valve leaks, causing blood to flow backwards toward the lungs instead of forward to the rest of the body,” said Dr. Fam, director of the hospital’s Cardiac Intensive Care Unit. “As a result, patients can develop heart failure, heart rhythm problems and other complications.”

Mitral regurgitation is most often treated by repairing the valve during open-heart surgery but the St. Michael’s team considered the 77-year-old from Oshawa too sick to survive such a surgery. They also decided that Adams’ valve was the wrong size and geometry for treatment with MitraClip.

“We’d been approached by Edwards, a medical device company, which needed our expertise in catheter-based intervention,” said Dr. Mark Peterson, a cardiac surgeon. “They were working on a minimally invasive method of replacing valves and chose St. Michael’s to test their new device because of our specialty in using catheters at the tip of the heart.”

While Adams’ heart was still beating, Dr. Peterson and interventional cardiologists Dr. Chris Buller and Dr. Fam guided the new catheter-based valve through the apex of Adams’ heart to the mitral valve. Once the new valve was deployed, it functioned perfectly and immediately reduced the pressures in his heart and lungs.

“An estimated 400,000 Canadians have moderate to severe mitral regurgitation and many of them,

like Keith, are too sick for open-heart surgery,” said Dr. Buller. “With the addition of MitraClip and transcatheter mitral valve replacement procedures, St. Michael’s is the only Toronto hospital able to offer the full range of therapeutic options for patients with mitral valve disease.”

Adams is still doing well and is grateful that he and his wife Melva–whom Adams met on a blind date in 1958–will be able to celebrate their 55th wedding anniversary in August.

Dr. Chris Buller and Dr. Mark Peterson during a cardiac procedure. (Photo by Geoff Koehler)

MitraClip therapy is a relatively new treatment. Using a catheter, surgeons and interventional cardiologists can use a MitraClip to clamp part of the leaky mitral valve and reduce mitral regurgitation.

February is Heart Month

FEBRUARY 2015 | IN TOUCH | 6

Dr. Stephen Hwang approaches Seaton House, Canada’s largest shelter for men, where he conducts a half-day a week clinic.

(Photo by Yuri Markarov, Medical Media Centre)

When should the City of Toronto declare an extreme cold weather alert, triggering the opening of warming centres for vulnerable and homeless people?

Good question.

The city’s Medical Officer of Health issues an alert when Environment Canada forecasts that overnight temperatures will reach -15 Celsius or colder. But Toronto Public Health, seeking more evidence about when to make those calls, has turned to the Centre for Research on Inner City Health.

Dr. Stephen Hwang, a leading expert on the health risks of homeless people, is leading a research project to determine the extent of cold and hot weather related injuries, such as frostbite, hypothermia and sunburn, and deaths among homeless people. He’ll then look to see whether there is a correlation to the temperature, the wind chill factor and the number of consecutive days of very cold (or hot) weather.

“There’s currently very little scientific evidence on which to base the decision,” said Dr. Hwang, who estimates the research will take another six months.

Cold weather alerts have been in the news this winter after two men presumed to be homeless died in one week in January, sparking calls for the city to do more to prevent them, such as open more shelter beds. Dr. Hwang said one part of the solution might be more street outreach to the small percentage of homeless people who sleep outside.

Getting the cold, hard facts

John Francis Carsone is one of the volunteers running the new information desk at the health centre located on Queen St. E.

(Photo by Yuri Markarov, Medical Media Centre)

A new information desk in the lobby of 61 Queen St. E. has made it easier for patients to visit the building.

The desk is open every morning Monday to Thursday, helping the patients who visit the site’s nine floors every year for everything from blood tests to well-baby checkups, gynecology appointments or to participate in research in the Clinical Nutrition and Risk Modification Centre.

Although there is an interactive touch screen directory on the back wall of the lobby, not everyone knows how to use it, said John Francis Carsone, one of the two volunteers who mans the desk.

“People want to be reassured of where they’re going,” he said. “I can help do that.”

Michael Kidd, director of Volunteer Services, said they realized there was a need for an information desk at 61 Queen because so many patients were going to the blood lab on the first floor, asking for directions.

New information desk saves time and energyBy Iram Partap

By Leslie Shepherd

FEBRUARY 2015 | IN TOUCH | 7

hours, they are deemed ready to move out of constant care.

Not every traumatic brain injury patient is a candidate, but the ones that are eligible have done extremely well.

“We were pleased to find out that on occasion, the successful participation in our call bell training was all rehab required to accept the patient,” said Sarah Wallace, a recreation therapist on 9CC. “For the first time, we’re transitioning patients straight from

Call bell story continued from page 1 constant care to rehab.”

Speeding up these transitions can make a big difference to a patient. Semi-private rooms are quieter and more comfortable, and moving to rehab means a patient is one step closer to home. The next patient on the ward benefits as well; in a program that operates at 94 per cent capacity, the sooner one patient transitions home or to another facility, the sooner the hospital can move the next trauma or neurosurgery patient out of the Emergency Department and into the ward. (Photo by Katie Cooper, Medical Media Centre)

Grant helps health care workers provide better breastfeeding support for new momsBy Kate Manicom

Breast milk is the most beneficial food a mother can give to her new baby. However, there are many obstacles, both physical and societal, that prevent a mother from breastfeeding. A 2014 study by Health Nexus’s Best Start Resource Centre, a health promotion organization focused on preconception and prenatal health and early childhood development, found that factors such as a woman’s age, ethnicity, education, social support and use of drugs or alcohol during pregnancy can all negatively affect the likelihood that she will breastfeed.

St. Michael’s catchment area includes many marginalized women who may be less likely to breastfeed. Thanks to a $50,000 grant from Health Nexus, a group of physicians and nurses on St. Michael’s Family Health Team has developed a project to provide more support for women who face barriers to breastfeeding.

Although part of the funding goes to patient education, much of it will help teach health care workers how to become involved at various stages in an expectant or new mother’s care to help her make an informed decision about breastfeeding. This can help them to identify and address challenges to breastfeeding early.

Dr. Lisa Graves, a family physician at St. Michael’s, said the project has already improved support for mothers who visit the family medicine sites.

“Often when we introduce clinical interventions we forget to communicate this information to clerical staff,” said Dr. Graves. “When we shared this project with our clerical staff, they suggested offering nursing mothers a private room to breastfeed. It was a wonderful idea that showed educating as many people as possible helps to create a breastfeeding-friendly environment. It’s an important lesson we’re sharing beyond our own team.”

The grant includes developing education materials for physicians and nurses across Ontario.

Dr. Nasreen Ramji, a family physician at the St. Jamestown Health Centre and a researcher with the project, said the benefits of breastfeeding extend beyond providing newborns with vitamins and nutrients they need to develop and helping to protect them against disease.

“It’s a cost-effective way to provide babies and toddlers a healthy, whole food,” said Dr. Ramji. “If a woman can breastfeed comfortably, it can help to reinforce the bond between her and her child.”

Dr. Graves said the project is not about pushing every woman to breastfeed. Instead, she stressed, “It’s giving every woman the support – the strength, power and information – to make the decision that’s right for her.”

Impacts of age, income and drug use on breastfeeding

Percentage of women with self-reported drug use in pregnancy: 42 per cent

Percentage of women who did not report drug use during pregnancy: 62 per cent

Percentage of Ontario women

who breastfed exclusively when they left hospital in 2012-2013

61.5%

Source: Populations with Lower Rates of Breastfeeding: A Summary of Findings, Best Start

Breastfeeding rate in neighbourhoods with the highest median household incomes: 68 per cent

Breastfeeding rate in neighbourhoods with the lowest median household incomes: 55 per cent

Age group with the lowest rate of breastfeeding: Under 20

Age group with the highest rate of breastfeeding: 30 to 34

Q & AQ. Tell us about your role.

I am kind of like air traffic control for the hospital – I track and troubleshoot how our patients flow from the ED, the OR and the ICUs, and try to optimize our use of beds.

A lot of my day is spent talking to people. I use electronic tools to track flow such as our bed management system, metrics from Decision Support, and there’s an ED tracker that tells me how many people are waiting in the ED at any time. The numbers are very helpful but often I just need to get on the phone with a CLM or charge nurse and help whoever needs help. I also attend all cluster meetings in the different areas every day, to help prioritize and troubleshoot problem spots for flow.

Another part of my role is to help St. Michaels plan for things such as holiday bed closures and flu, and I support corporate projects to help predict how changes in process, demand or capacity could affect patient flow

Q. How did you get into this line of work?

I’m a registered nurse. Before I started in this role two and

SUSAN CAMM, CORPORATE CASE MANAGER, CORPORATE PATIENT FLOW PERFORMANCE

half years ago, I was front line in the ED for eight years. I really miss seeing patients at the bedside, but I’ve always been interested in patient flow and it was a great opportunity to try to approach care from a systems level. It’s been really helpful to have the bedside perspective and be able to understand first-hand the challenges our front-line staff face.

Q. The past several weeks have been challenging for patient flow. What have you been seeing?

The holidays were tough. I see people stepping up every day, and working incredibly hard. I can’t emphasize enough how hard the clinical teams have been working.

Q. What do you love about your job?

It’s great to know that if I can help improve patient flow, there will be real, concrete benefits for patients. For example, some patients will get to go home sooner, or we will be able to provide more surgeries. These are benefits for individual patients but they also add up to a better system.

Q. If you didn’t work in health care, what do you think you’d be doing for a living?

Maybe I’d be a chef - they say kitchens are just as stressful as any ED or OR!

By Emily Holton

(Photo by Katie Cooper, Medical Media Centre)

INTOUCH FEBRUARY 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