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

INTOUCHSEPTEMBER 2015

Minimizing exposureBy Geoff Koehler

Dr. Dan Werb wants to prevent potential injection drug users from ever starting, by limiting their exposure to experienced injection drug users. (Photo by Yuri Markarov, Medical Media Centre)

Dr. Dan Werb wants to prevent potential injection drug users from ever starting, by limiting their exposure to experienced injection drug users. He also wants to increase the opportunities people who inject drugs have to find recovery support when they need it. Luckily, his new research may accomplish both.

Dr. Werb heads a research project called PRIMER, or Preventing Injecting by Modifying Existing Responses. It was partly inspired by the successful Treatment as Prevention model for reducing HIV prevalence that uses antiretroviral drugs to reduce HIV viral loads to very low or undetectable levels, thereby reducing the risk that HIV-positive people will infect

others. Instead of improving access to antiretroviral medication, however, PRIMER will test whether improved access to public health programs such as methadone clinics and supervised injection sites reduces the risk that people who inject drugs initiate others into injecting.

“It seems that first-time drug injectors most often begin injecting because they’ve been exposed to veteran injectors and become desensitized—to the point where the drastic step of sticking a needle in your arm seems normal,” said Dr. Werb, a scientist with the Li Ka Shing Knowledge Institute of St. Michael’s Hospital.

Dr. Werb—who has a PhD in epidemiology and expertise in HIV and addictions research—said the key to

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preventing this exposure is expanding existing public health services for the 100,000 Canadians who already inject drugs, typically cocaine, heroin or other opioids such as OxyContin.

“This research will determine whether, by creating more supervised injection sites such as Insite in Vancouver, we can provide safe, private places for injection drug users, while limiting the exposure of those who have never tried injecting drugs,” said Dr. Werb.

Scaling up public health services also improves the likelihood those who are injecting drugs may find recovery support. The more frequently that people who use drugs access public health services, the more frequently they interact with trained support workers.

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Collaborative learning a key way to empower you to be part of the patient journey

St. Michael’s has a rich history of fostering collaborative learning opportunities, which happens when two or more learners from different perspectives learn with, from and about each other. This model of learning was first led by our health disciplines professional practice and has become common practice at the hospital. It is a key pillar in our Education Strategic Plan and a corporate priority within the hospital’s Strategic Plan. It has been the foundation of our monthly Interprofessional Education Series since 2008 and our Student Cafés since 2010. Collaborative learning is also a key component in our Quality Improvement Fellowship, which for the first time has been co-designed by the Education and Quality teams. The

fellowship, which includes a workshop on collaborative leadership, focuses on gaining knowledge and developing skills to do quality improvement work and the participants work together as teams on a project related to the St. Michael’s Quality Improvement Plan.

In recent years, there has been significant interest in transforming health professions education and health-care delivery through collaborative learning and practice. This has been evident in educational reform reports, such as The Lancet Commission’s “Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World” in 2010, as well as in new North American accreditation standards and Canadian health-care policy.

One of the biggest benefits of collaborative learning is that people gain a better understanding of how their individual and collective knowledge can impact and enhance a patients’ care. This also means

including patients and families in our everyday work as part of the team; providing care with patients as partners in the journey. Our Collaborative Learning Student Placements are an excellent example of how collaborative learning enriches the experience for the learners. These placements have been developed to include both clinical and non-clinical learners.

Collaborative learning is now being incorporated into our corporate education programs including the Senior Friendly Hospital Initiative and the least restraint training program. We are pilot testing an Interprofessional Care Competency Framework in the Allan Waters Family Simulation Center and this will help guide our future development and assessment of new collaborative learning opportunities.

I’m a firm believer that we are all students no matter how many years it has been since we set foot in a classroom. Learning is a lifelong adventure and I am excited to further embed collaborative learning across the hospital.

Follow St. Michael’s on Twitter: @StMikesHospital

“Because timing is so important for recovery, increased services will also increase the opportunities people who use drugs are around someone they can ask for help at the moment they are ready,” said Dr. Werb. “PRIMER will investigate a way to both prevent new cases of injection drug use and treat the harms experienced by people who have already started.”

In 1993, Switzerland expanded supervised injection sites and methadone maintenance therapy as part of a comprehensive public health approach to reducing drug-related harms. At the time, new injectors comprised 18 per cent of all injection drug users in the country.

“By 2000, new injectors only made up three per cent of

all people who injected drugs in Switzerland,” said Dr. Werb. “This suggests that a comprehensive scale up of harm reduction services might actually reduce the socially contagious nature of injecting.”

The U.S. National Institute on Drug Abuse seems convinced by Dr. Werb’s plan. He was recently named one of four inaugural recipients of the institute’s US$1.5 million Avenir research award, a fund set up to support highly innovative research from new scientific investigators.

The PRIMER study will be carried out over the next five years with an international team of researchers across six cities: Vancouver; San Diego, Calif.; Tijuana, Mexico; and Paris, Marseille and Bordeaux, France.

Minimizing exposure story continued from page 1

Patricia Houston Vice President of Education

OPEN MIKE with

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

Each week, Tanya Aziz volunteers as an Emergency Department escort for four busy hours. She greets incoming patients, guides them to the registration desk, fetches warm blankets, brings sandwiches and juice boxes to hungry patients, gathers lost wheelchairs and helps family members find their loved ones waiting in beds or cubicles. And answers lots and lots of questions.

“It’s dynamic, it’s exciting, and there’s always something to do,” said Aziz, a biomedical science student at Ryerson University. “People coming to the Emergency Department are often nervous and they don’t know where to go. As a volunteer, I try to help make them feel more comfortable and at ease.”

Aziz is one of 10 volunteers serving in

the ED. Each volunteer works three- to four-hour shifts once a week, either in the afternoons or evenings.

Michael Kidd, director of volunteer services, said the volunteers don’t require a specific background or training.

“We look for people with the right attitude and customer service skills who can improve the patient experience,” he said.

This volunteer program was reintroduced in January in anticipation of the expansion of the emergency department, which already sees 75,000 patients a year and will physically double in size following completion of the 3.0 renovations.

“When the unit is twice as large as it is now, I think the role will become even more important,” he said.

Volunteers help connect the dots in the Emergency Department

Volunteer Tanya Aziz assists a patient in the Emergency Department. There are 10 volunteers serving in the ED, which sees 75,000 patients a year. (Photo by Katie Cooper, Medical Media Centre)

By Corinne Ton That Kidd said that as the ED grows, he expects the volunteers will be “more and more helpful in fostering as positive patient and family experience.”

Triage nurse Daniel Vaillancourt said the volunteers have made a big difference.

“They do a lot of the extra things that save us time, like walking a patient somewhere, greeting them, finding what they’re here for and answering some of their questions,” he said. “It helps with the flow of things.”

Aziz said the volunteer position is a fulfilling role that allows her to engage with patients one-on-one.

“It makes you feel really good, like you’re really making a difference,” she said.

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Before patients with kidney disease can begin hemodialysis, there needs to be a way to remove blood from the body and return it after it has been cleaned.

Ideally, a surgeon would create a fistula, connecting an artery and a vein in the arm to create one stronger channel and increase the amount of blood flowing out to the hemodialysis machine.

But many patients are not candidates for a fistula because their veins are too small or they have stenosis, or narrowing, in spots.

Some may have a graft implanted, artificially connecting the artery and vein. And now at St. Michael’s there is another option.

Dr. Elisa Greco is the first surgeon in Ontario to perform a hybrid vascular access procedure using a product that was recently approved for use in Canada: a stent attached to a tube, or graft.

The stent is inserted into a vein, which is then connected to the artery via the graft.

The stent is what makes this new product unique, as it opens the vein to boost blood flow.

New product and procedure help prevent dialysis complications

St. Michael’s Dr. Elisa Greco is the first surgeon in Ontario to perform a hybrid vascular access procedure using a new product. Both the procedure and the product help boost a patient’s blood flow for successful dialysis. (Photo by Katie Cooper, Medical Media Centre)

By Melissa Di Costanzo The standard grafts that are used for dialysis are often complicated by vein narrowing, which leads to clotting. The new product, combined with the hybrid procedure Dr. Greco performed, helps prevent this complication.

“Patients on dialysis come into the hospital about three times per week for their treatment,” said Dr. Greco. “This is their lifeline. We want to do everything possible to prevent complications and frequent interventions for the patient.”

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Novel surgery offers new hope for breast cancer patients

Dr. Adena Scheer is the only physician at St. Michael’s – and one of few in Canada – mastering a new, less invasive way to preserve and reshape tissue following breast cancer surgery.

Mastectomies or lumpectomies are both traditional procedures that help to eradicate cancer. Both can cause scarring and disfigurement.

Oncoplastic surgery allows for remaining tissue to be shifted and sculpted after the tumor is removed, leading to fewer deformities and a shorter recovery time. The procedure can be as short as two to three hours and patients don’t require an overnight hospital stay or home care. Patients can also choose to have the other breast modified to create evenness.

It’s not for everyone. The size of the tumor, the size of the tumor relative

to the patient’s breast and the patient’s preference are all considered before a decision is made. But for those who are willing and able to opt in, the result is a smaller, more lifted breast with a natural appearance – and many patients are thrilled with the outcome.

“I get a lot of hugs,” said Dr. Scheer, whose area of clinical expertise is breast surgical oncology. “After they get over the shock of learning about their cancer, we can tell them we’re able to preserve their breast, and that cancer doesn’t mean their breasts are left completely unrecognizable, and they’re thrilled.”

Dr. Scheer is accustomed to hearing her breast cancer patients say: “Just remove the cancer; I just want it gone.”

“Now, we’re employing tools to afford women a better cosmetic outcome,” she said. “We can’t bury our heads in the sand and think that surgery like this

Dr. Adena Scheer practices oncoplastic surgery, which allows for remaining breast tissue to be shifted and sculpted after the tumor is removed. (Photo by Katie Cooper, Medical Media Centre)

By Melissa Di Costanzo won’t impact patients emotionally – it absolutely will.”

Dr. Scheer trained with a physician in Paris for five months to learn about oncoplastic surgery before coming to St. Michael’s after completing a fellowship in surgical oncology. She learned about the technique when she was a general surgical resident at the University of Ottawa.

Her interest in working with breast cancer patients stems from her research interest: taking information and making it digestible and usable for both patients and providers.

“Breast cancer patients are engaged in their care: they’re curious, they like to talk about options, and they’re interested in learning more about their disease,” she said. “I like being part of that shared decision making process with them.”

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An inside look at the new ambulatory exam rooms

The first thing Nancy Rudyk noticed when she toured the mock-up of the new standardized ambulatory clinic exam room was how big it was and the natural sunlight streaming through the window.

“It’s roomy and it’s going be really fantastic for our patients,” said Rudyk, interim clinical leader/manager for the Pre-Admission Facility. “It seems really functional and efficient.”

The ambulatory clinic exam room is the first in a series of mock-ups Bondfield Construction is building for units and clinics that will be part of the new Peter Gilgan Patient Care Tower or in renovated areas of existing hospital space. Staff will be able to tour them to provide final comments on design before construction of each area begins. The exam room was housed temporarily on 9 Donnelly, but mock-ups of other areas, ICU rooms and OR suites for example, will pop up in coming months.

A similar suite of mock-ups was built on the seventh floor of the Li Ka Shing Knowledge Institute in 2012 and helped

inform earlier stages of design.

Rudyk toured the mock-up room with Mary Ann Purdon, a nurse with the PAF. Both have been involved in the planning process of the PAF spaces, offering suggestions on the design and layout of the rooms.

The new PAF exam rooms will include stretchers with bars on the sides rather than exam tables, anti-splash automated sinks, larger windows and more space for visitors. They’ll also be more accessible for patients, providing enough space for seniors to move comfortably in and out of the room.

PAF isn’t the only group moving into the new spaces, which are based on standardized exam rooms. Multiple Sclerosis, Electromyography and Ophthalmology will also be move into the renovated ambulatory clinics on the upper floors of Donnelly.

Once complete, the rooms will feature slight variations to accommodate the different types of patients. Ophthalmology exam rooms, for example, will have chairs instead of stretchers and will include more specialized equipment.

Nancy Rudyk, clinical leader/manager for the Pre-Admission Facility, and RN Mary Ann Purdon review equipment in a mock-up of the new standardized ambulatory clinic exam room that was built on 9 Donnelly. (Photo by Katie Cooper, Medical Media Centre)

By Corinne Ton That Michael Keen, senior director of Planning and Development, said standardized rooms permit different groups to share the same space, and allow clinical staff to work in different clinics without having to readjust to new rooms.

“Not having designated rooms for each clinic definitely helps level out scheduling challenges,” said Keen.

For Rudyk and Purdon, touring the mock-up space allowed them to better visualize the room and offer additional feedback before the designs were finalized.

“We’ve done it on paper, and it’s so much easier to see it in person,” said Purdon. “It also makes you feel more confident that what you’ve asked for is coming together.”

Construction on the ambulatory spaces has begun, and both nurses are looking forward to moving into the new PAF on 10 Donnelly.

“It’ll be safer, especially for seniors, brighter, and more of a positive experience for our patients,” said Purdon.

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Life after trauma program first step towards recovery

Trauma suffered in childhood – such as emotional or physical abuse – can significantly affect a person’s physical and mental health well into adulthood. To help these people finally heal, social workers in the St. Michael’s Academic Family Health Teams began a Life After Trauma program that has treated more than 200 people.

The program teaches life skills in a group setting over 10 weeks. For most it’s their first interaction with a mental health setting.

“We give people the skills to start to understand how their beliefs and behaviours are connected to the events of the past,” said Celia Schwartz, a social worker based at the Health Centre at 80 Bond.

Patients may have physical ailments such as fibromyalgia and chronic pain or destructive behaviours such as substance abuse or eating disorders. Although they may not be diagnosed with post-traumatic stress disorder, they will identify the root cause of these behaviours as traumatic abuse in childhood such as sexual, physical or emotional abuse.

“Our group caters to individuals

who are able to identify and want to work on this issue,” said Schwartz.

The need for the Life After Trauma program arose when the number of referrals was greater than the team could handle on a one-to-one basis. The group sessions host an average of 10 participants. There are few resources available elsewhere in the city, especially for men, and they often have lengthy waiting lists.

The program is based on several sources including the book “Life After Trauma,” which was adapted to the primary care setting by Schwartz and fellow social workers Ashley Shultz, Amy Babcock and Heather Campbell. Schwartz and Babcock co-facilitate the women’s group and Schwartz and Campbell co-facilitate the men’s group. Social work students are also involved, observing sessions at first, and later co-facilitating a session as part of their Master’s program.

There are three core modules – trauma symptoms, core beliefs and triggers. The program consists of understanding key areas impacted by trauma: relationships

By Greg Winson

and self-esteem and how to cope with impacts that most survivors feel such as shame and anger. Patients in the program learn from each other in group discussions and through class exercises.

“It’s a way of opening up a discussion when people haven’t had it before,” said Schwartz.

The program acts as a first step towards recovery.

“It’s focused enough with sizable goals that look at how we move people forward in a realistic manner,” said Schwartz. “We want to have enough impact that we’re getting people in the right direction.”

Academic Family Health Team social workers: Celia Schwartz, Heather Campbell, Amy Babcock and Ashley Shultz. (Photo by Yuri Markarov, Medical Media Centre)

Q & ADr. Helena Frecker is the chief clinical fellow for the next year, only the second person to hold this position. She completed her Ob/Gyn residency at St. Michael’s and is in the final year of her fellowship in minimally invasive gynecological surgery.

Q. Tell us about the role of chief fellow.

The chief clinical fellow is a relatively new role. It was created last year to provide clinical fellows with an advocate at St. Michael’s. Unlike residents who are automatic members of the Professional Association of Residents of Ontario, the body that advocates on their behalf on educational and professional concerns, clinical fellows don’t have a resource like this, so the hospital created my position to provide a voice for our fellows at the hospital. In addition to sitting on the Student Experience and Postgraduate Medical Education Committees, I am available to assist any clinical fellow who may not know whom to reach out to at the hospital about a particular issue, create opportunities for our fellows group to connect socially, and promote ways we can find balance amidst our busy clinical responsibilities. Since I’m still new to this role myself I’m still feeling my way through a lot of this.

DR. HELENA FRECKER,CHIEF CLINICAL FELLOW

Q. What’s a typical day like for you?

Most of my time is spent on the clinical side. If I’m not in the operating room, which I am at least two or three days per week, I am seeing patients in the Women’s Health Clinic. However, I do use the downtime I have during the day to reach out to the fellows via phone or email. It’s important for me to check in and let them know I’m here should they need anything. One fellow new to Canada contacted me recently to ask for help finding an obstetrician for his pregnant wife. I made a few calls on his behalf and found them an appointment for the next day.

Q. What are you most looking forward to in your role?

I’m really looking forward to getting to know the other fellows and building more of a fellows community at the hospital. I have a great relationship with the ones I work with in obstetrics and gynecology and having the opportunity to hear about other people’s experiences here will be interesting.

Q. How do you unwind at the end of the day, what’s your guilty pleasure?

I’m a musician in my (limited) spare time, so I really enjoy sitting down with my guitar and recording music in my home. My band’s album, Beneath the Ice, is on iTunes.

By Heather Brown

(Photo by Katie Cooper, Medical Media Centre)

INTOUCH SEPTEMBER 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.

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