Printed on 100 per cent recycled paper DECEMBER 2015 / JANUARY 2016 | IN TOUCH | 1

By Kendra Stephenson

Carrie Hunt, a volunteer in the Family Support Program, cuddles a baby in the NICU. (Photo by Yuri Markarov, Medical Media Centre)

Carrie Hunt rocks a newborn baby in her arms, singing softly. The baby sleeps soundly, swaddled in a pink blanket and hand-knit hat. Hunt is a volunteer with the Family Support Program in the Neonatal Intensive Care Unit, cuddling tiny babies every Friday afternoon.

St. Michaels NICU launched the program at the beginning of November, where carefully selected volunteers cuddle infants when their parents cant be present, help entertain siblings while their parents are caring for the newborn, and provide companionship to families during their time in the unit.

In its short existence here, the program has been very popular with our staff, families and volunteers, said Amanda Hignell, a social worker in the NICU.

Life doesnt stop when you have a sick child and families cant always be here so our volunteers help and fill in wherever possible.

The program, proposed and developed by Hignell and Karen Carlyle, a nurse practitioner, builds on the observed benefits of baby cuddling as well as research that has shown health improvements in infants resulting from a caregivers touch.

This practice is already a standard of care in many U.S. regions, said Carlyle. Based on the evidence and success, Continued on page 2

INTOUCHDECEMBER 2015 / JANUARY 2016

St. Michaels has also recently made the program a standard in our NICU which is really exciting.

The program runs seven days a week with a morning shift from 9 a.m. to noon and an afternoon block from 1 p.m. to 4 p.m., rotating among 13 volunteers. During a cuddling session, volunteers stay seated while a nurse places the infant in their arms. Volunteers are encouraged to sooth, sing and read to the babies while holding them, but do not provide care.

This initiative is different because the volunteers have physical contact with patients in an intensive care environment, said Carlyle. We worked closely with volunteer services and have been selective in the hiring process.

Snuggle science launches in St. Michaels NICU

DID YOU KNOW? Cuddling programs have been a standard of care in many U.S. regions since the 1990s

DECEMBER 2015 / JANUARY 2016 | IN TOUCH | 2

Every day, I come to the hospital filled with gratitude. I am grateful for being a member of this incredible St. Michaels Hospital family. I am inspired by the work you all provide our patients, their friends and families, and how you work with your own colleagues. So as we head into the holiday season, I want to take this opportunity to thank all of you for your service at St. Michaels.

As CEO, I receive countless emails, letters and phone calls from patients, visitors and our community partners

Bob Howard, President and CEO

expressing their gratitude for the care provided at the hospital. And most of the time, it isnt about the medical care. Its about the compassion, human dignity and excellent service shown to all, be it from the staff or volunteers at the Info Desk who greeted them when they entered, or the smile from the employee when their meal was delivered, to the nurse providing comfort when the patient was at their most vulnerable moment. For this I am grateful to you all.

These are tough times, for sure. We have experienced high patient volumes and more complex patient needs in recent years. That trend unfortunately is not going to change. I want to thank you for your innovation, ideas and willingness to change to meet the future needs of our community and to continue to provide the best quality care to our patients.

My promise to you is that I and other senior leaders will do everything we can to support all those who work at St. Michaels as we undergo these changes.

We have also had some challenging months on the leadership team this past fall. Despite that, I am very proud that as an organization, we maintained our values. I want to thank the members of our board of directors for their guidance and take this opportunity to express my gratitude for their volunteerism and commitment to St. Michaels.

So, at this holiday season, I give thanks. Thanks for the honour to lead this organization made exceptional by the kindness and quality of service delivered by its clinicians, staff, volunteers and all who support St. Michaels. Please accept my best wishes for you, your family and friends and all the best for 2016.

OPEN MIKE with

Follow St. Michaels on Twitter: @StMikesHospital

Successful volunteers completed health screenings, a police background check, interviews and a half-day training session.

Hignell and Carlyle also created an extensive orientation that incorporates a volunteer manual with simulations and situation-based scenarios. The training includes information on NICU terminology, common conditions, infant cues and infection control.

Hunt said the training was extremely helpful and taught her how to best interact with NICU staff, families and babies. Hunt, an aspiring occupational therapist with a Masters in rehab science, has always wanted to work with children, especially those with special needs.

I have really enjoyed my experience with the program, said Hunt. Holding the babies, seeing their little faces react and eyes open is very special. Ive seen a few babies go home already its rewarding knowing you have contributed in some small way to their recovery. I feel like a part of the health team.

Theres also a research component to the program, looking at babies experiencing opiate withdrawal. Data will be collected as part of an Infant Cuddlers Study to evaluate whether hospital stay lengths are reduced with cuddling from volunteers in the Family Support Program for babies who are in the NICU because of opiate withdrawal.

Marginalized and vulnerable populations are an important demographic of St. Michaels, recognizing that each family

can have unique challenges, said Hignell. I think St. Michaels is fantastic at coming up with solutions and innovations to provide compassionate care for all our patients regardless of their circumstance.

Snuggle Science story continued from page 1

I can no other answer make, but, thanks, and thanks William Shakespeare

DECEMBER 2015 / JANUARY 2016 | IN TOUCH | 3St. Michaels is an RNAO Best Practice Spotlight Organization

St. Michaels Food Services Department is a busy place filled with delectable aromas and never-ending activity. On an average day more than 1,200 patient meals are prepared over the course of breakfast, lunch and dinner. But the food service team does not stop there.

As part of its Community Food Service Program, the chefs also cook meals for a number of community organizations in the downtown core, including Meals on Wheels, The Second Mile Club and the Dixon Hall Neighbourhood Services.

In a separate section of the kitchen from where the patient meals are prepped and assembled, a small team of people dish out and package the community meals that have been prepared by the chefs on the other side of the kitchen. The assembled meals are taken to the hospitals loading dock for delivery to clients downtown, in most cases seven days a week.

Alvin Hoang, a food service worker, packs meals for the Community Food Service Program. (Photo by Yuri Markarov, Medical Media Centre)

By Heather Brown

St. Michaels Food Services team, more than just in-patient meals

For the Meals on Wheels program alone, 80 meals are prepared during the week and 60 meals on the weekend. The menus change as the seasons change. Meals include a hot and cold selection daily. Clients may also order an additional cold lunch option, which includes a sandwich, drink and dessert to supplement their evening meal. St. Michaels is one of only two hospitals in the Greater Toronto Area to provide this service to the community.

The Community Food Service Program is a great way to provide regular meals to our clients who are unable to cook for themselves or need assistance with their

meals, said Melani Ragnitz, the manager of Food Services. Although the community agencies pay St. Michaels for the meals, knowing that our efforts provide our clients in need with a nutritious meal, is a motivating factor for us to continue to provide this program to our community.

In addition to the Community Food Service Program, the team also provides food to internal stakeholders, such as St. Michaels Withdrawal Management Service. The clients in this program benefit from a hot dinner every day as well as sandwiches for lunch and groceries to be used for breakfast each day.

DID YOU KNOW?

The Community Food Service Program uses 227 loaves of bread, 253 containers of yogurt and prepares more

than 6,323 meals a week.

Approximately 1,800 items are transported through the hospitals pneumatic tube system daily. Maurice Rotsaert, a supervisor for Mechanical Engineering and Plant Services, inserts a canister into the system. (Photo by Katie Cooper, Medical Media Centre)

Behind St. Michaels walls is a hidden network of tubes where lab samples, medications and documents travel at speeds of up to 7.5 metres a second. Connecting the entire hospital, the pneumatic tube system propels cylindrical canisters by a combination of air pressure and vacuum, and delivers crucial items to their destinations rapidly, unobstructed by heavy foot traffic or elevator delays.

Every part of the hospital is linked, including the pharmacy, labs and each nursing station. With the exception of items such as hazardous materials, narcotics, pathology specimens and blood transfusions, almost anything weighing less than seven pounds can be transported by the tubes. And with an average travel time of three minutes, the system is vital to providing patient care efficiently and helping to accelerate decision-making.

One of the highest users is the hospitals pharmacy. Peter Davies, manager of Pharmacy Technical Operations, said his department uses the system continuously.

The pharmacy sends literally hundreds of doses by the tubes throughout the hospital every day, said Davies. In the dispensing process, the slowest step is getting medication from the pharmacy to clinical staff on the units. The system helps clinical staff to administer medication in the most efficient way possible.

The hospitals laboratories also use the tubes consistently, typically receiving a specimen every five minutes, with the highest volumes from the Emergency Department and the intensive care units. Shane Buchanan, manager of Hematology and Specimen Management in the Department of Laboratory Medicine, sees the system as an integral part of patient care.

When the labs can receive specimens almost as soon as they are collected were able to provide timely results for patients who need them most and provide a measurable impact on patient care, said Buchanan.

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In early 2016, the entire pneumatic tube system will be upgraded as part of St. Michaels 3.0 infrastructure projects. The system, retrofit in 2010, will have new stations in the Medical Device Reprocessing Unit, Logistics and Medical Records, and relocated stations in the Emergency Department to reduce traveling distances for staff. It will also be expanded into the Peter Gilgan Patient Care Tower and the renovated ambulatory clinics on the upper floors of Donnelly Wing.

Fast-tracking patient care at 27 kilometres an hour

The system helps clinical staff to administer medication in the most efficient way possible.

Peter Davies, manager of Pharmacy Technical Operations

By Kate Manicom

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By Greg Winson

St. Michaels doctor develops skills test for surgical residents

Dr. Sandra de Montbrun evaluates a surgical fellow in the Allan Waters Family Simulation Centre skills laboratory. (Photo by Katie Cooper, Medical Media Centre)

exam identifies technical deficiencies in people who would otherwise go on to be certified with the current board certification process.

For 2014, the Colorectal Objective Structured Assessment of Technical Skill, or COSATS, exam became a mandatory component for certification for the American Board of Colon and Rectal Surgery. It was the first time in North America that a technical skills exam was a required component for certification.

The purpose of the exam was to collect data on the exam itself, said Dr. de Montbrun. Candidates were not assigned a pass/fail status, but we had to administer it to the entire cohort of people to get an idea of what the data would look like with the entire group of examinees taking their board exam. The results of this most recent pilot have been submitted for publication.

There is no timetable for the COSATS exam to become a permanent component of The American Board of Colon and Rectal Surgery exam. At the same time, the American College of Surgeons is interested in moving forward with a technical exam for general surgery training in the United States.

The Royal College of Physicians and Surgeons of Canada does not yet have plans to incorporate the COSATS into Canadian certification.

A technical exam for colorectal surgery fellows piloted by a St. Michaels physician could lead to a paradigm shift in certification for all surgical fellows.

Surgical residents are currently assessed on their knowledge through written exams and for their judgment through oral exams. However, there is no formal assessment of technical skill at the time of certification.

Dr. Sandra de Montbrun, a colorectal surgeon , has been working with the American Society of Colon and Rectal Surgeons to develop a technical skills exam for the purpose of certification in the United States.

This is the first time that any North American surgical society has moved forward with developing a technical skills exam with the purpose of certification for high stakes assessment, said Dr. de Montbrun.

Implementing this sort of test could lead to improved patient outcomes.

If we can identify the residents who show deficiencies in technical skill and remediate them during their training, there is a potential impact on patient care, she said.

The technical exam takes place in a surgical skills lab setting and is made up of eight different technical skill tasks. The students are observed by an examiner who evaluates their performance.

She has led three pilot studies to prove the validity of the technical exam. The first study, held at the University of Toronto in 2011, compared general surgery residents to colorectal residents.

We found there was a difference in their performance, giving some initial evidence of validity to the test, said Dr. de Montbrun. The results from the second pilot study suggested that this

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The top two images compare mild and severe scarring using conventional MRI technique. The bottom two images contrast mild and severe kidney scarring with the new MRI technique being tested in transplanted kidneys at St. Michaels. (Images courtesy of Dr. Kirpalani and Dr. Leung, St. Michaels MRI Research Centre)

Using MRIs to predict kidney failureBy Geoff Koehler

Ten years after transplantation, up to 60 per cent of patients kidneys have some degree of scarring that can cause kidney failure.

Weve begun using MRI to measure a transplant kidneys stiffness, said Dr. Kirpalani, a radiologist and director of St. Michaels MRI Research Centre. Stiffness is an early sign of scarring, and this has been shown with MRI in organs other than the kidney. Healthy tissue is more flexible whereas scar tissue is more rigid.

The team has begun studies to evaluate whether MRI can measure kidney scarring in patients more safely and accurately than biopsy. Unlike biopsy, the MRI test does not require needles or injections and MRI can analyze the whole organ for scarring, rather than just the small biopsy sample.

Weve already tested this technique in more kidney transplant patients than anywhere else in the world, said Dr. Kirpalani. If were able to detect scarring more safely and accurately than a needle biopsy, we may be able to better guide how kidney transplant patients are treated early on and improve their long-term outcomes.

One in every two patients diagnosed with kidney failure will not be alive in three years.

The major reason that kidneys fail is scarring, said Dr. Darren Yuen, a nephrologist with St. Michaels Hospital. If we could figure out who has a lot of scarring, we could better predict which patients are most likely to develop kidney failure and treat these patients more aggressively.

Scarring is irreversible and can cause ongoing kidney injury that can eventually leads to kidney failure. Regardless of whether a patient has diabetes, high blood pressure or another condition affecting the kidney, all these diseases can cause scarring, which ultimately can lead to organ failure.

Needle biopsy is the current gold standard diagnostic test for assessing kidney scarring. A long needle is injected into the kidney and a sampleabout the size of a mechanical pencils tipis removed from the organ.

The problem with biopsy is that such a small sample means even after patients undergo this painful test, we still dont know what most of the kidney looks like, said Dr. Yuen, who is also a scientist in the hospitals Keenan Research Centre for Biomedical Science. The sample may show no scarring, but the rest of the organ may be severely scarred. We have no way of knowing and so clinicians are hesitant to subject patients to a test that provides limited information and has risks such as internal bleeding.

Dr. Yuen teamed up with Medical Imaging specialists Dr. Anish Kirpalani and Dr. General Leung to apply and study a specific magnetic resonance imaging testcalled an elastogramand its ability to detect scarring in transplanted kidneys.

If their new MRI technique is able to quickly and clearly tell the difference between mild and severe kidney scarring, it may prove particularly helpful for kidney transplant patients.

In the first year after surgery, patients with transplanted kidneys generally do very well. Their long-term prognosis, however, is unfortunately not as good, said Dr. Yuen.

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Patients who have experienced multiple traumas now have a better chance of survival and a faster recovery thanks to a technique that was used for the first time in Canada on a trauma patient at St. Michaels.

The procedure is called Resuscitative Endovascular Balloon Occlusion of the Aorta, and it can be used on trauma patients who are experiencing life-threatening bleeding.

Using a series of guide wires, a thin plastic tube with a balloon at the end is fed through a vessel in the groin to the patients aorta, the main blood vessel that supplies the body. It is positioned upstream of the bleeding point. Once in place, the balloon is inflated, blocking the blood flow to the bleed point, stemming the blood flow and bleeding

while the patient is being resuscitated and operated on.

Often, patients are bleeding so much they arent able to make it to the operating room in time. REBOA helps to stop the bleeding quickly, getting the patient to the operating room and on the road to recovery, faster.

Before REBOA, surgeons such as Dr. Sandro Rizoli, director of trauma, would perform thoracic surgery, opening the chest wall to put a clamp on the aorta to stop the bleeding exposing the heart and lungs. Now, surgeons can make an incision in the groin to insert the balloon a much less invasive procedure. An X-ray is used to ensure the balloon is inserted and placed properly.

Members of the vascular, interventional radiology and trauma teams used the

technique on a trauma patient for the first time in October.

The technique is familiar to vascular surgeons, where it is used for patients undergoing surgery to repair aortic aneurysms , said Dr. Mark Wheatcroft, the vascular and endovascular surgeon who participated in the pioneering procedure.

The beauty lies in its speed and simplicity, he said.

Dr. Rizoli said this approach benefits patients who otherwise may not stand a strong chance at survival.

Anywhere from 40 to 50 people come in every year with massive bleeding, and this technique will give some of them a chance of survival and rapid recovery, he said.

By Melissa Di Costanzo

Trusted vascular technique offers patients with multiple traumas better chance of survival

Dr. Sandro Rizoli, director of trauma, was recently involved in a procedure that helps give trauma patients a better chance of survival. Dr. Rizoli is holding a tube with the balloon that helps to block blood flow at the bleeding point while the patient is being resuscitated and operated on. (Photo by Yuri Markarov, Medical Media Centre)

Q & ACheryl Proc is a team leader within the FOCUS team at the Sumac Creek Health Centre. She has worked at St. Michaels Hospital for 13 years.

Q. Tell us about your role and the FOCUS team.

The FOCUS team is a multidisciplinary outreach team that works with people with severe and persistent mental illness. Its a partnership between St. Michaels Hospital and Cota, a community-based mental health organization. Our clients often face challenges around repeated hospitalizations and need support for their mental health needs. We practice things like medication management and helping people with the activities of daily living. Were very recovery focused, so we help people with any educational or vocational goals they might have. We also have clients experiencing issues of homelessness, poverty and legal challenges.

Q. What does your average day look like?

We start every day with team rounds, where we find out about any issues that happened during the evening shift, and talk about major issues for the day. We have 160 clients some of those clients we see every day. But every day is different. We see people in the community, in the office, in their homes, and we have some clients who are homeless, so well meet them on the street corner for a conversation and see how we can help them. Most team members see about six or seven clients per day.

CHERYL PROC,TEAM LEADER, FOCUS TEAM

Q. Why did you decide to focus on mental health and addictions?

Im a social worker by training. Mental health was a natural fit for me because I was always curious about issues affecting people in society and life. I started at St. Michaels as a student during my undergraduate studies. I fell in love with the work and the organization and very much believe in what were trying to accomplish.

Q. Whats the most rewarding part of your job?

To take people to a place where theyre seeing some of their hopes, dreams and goals come true. Thats something that I think Im really fortunate to be a part of. So its very rewarding to be part of someones recovery process, and see people move from being in not such a great place in their lives, to experiencing wellness.

Q. Christmas can be a tough time for anyone especiallyif you dont have family. What does the FOCUS team do to help people through the holidays?

Many of our clients arent connected with family or friends, so they often feel very lonely or isolated. Part of the work we do is making sure people feel supported and cared for. Were there to help them through what could potentially be a hard time. We go to our clients houses, spend time with them and take them to the movies. We also have a client holiday party that we throw at a local community centre in December. So we try to be a part of their lives even during that period. We have about four people on the team wholl be working on Christmas Day and New Years. A big part of our role is making sure people dont have to be alone. And we try to bring some fun to their care, through outings and parties.

By Corinne Ton That

(Photo by Yuri Markarov, Medical Media Centre)

INTOUCH DECEMBER 2015 / JANUARY 2016In 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.

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