St Michael's Hospital Research Articles

Time from surgery to first adjuvant chemotherapy: Experiences at two Toronto hospitals.

e17557 Background: Optimal treatment of patients with colorectal cancer (CRC) includes the timely administration of adjuvant chemotherapy (AC). While Cancer Care Ontario (CCO) guidelines advise that CRC patients receive their first AC no later than 8 weeks after surgical resection, new data suggests treatment should begin between 4 and 6 weeks. This retrospective study was performed to determine the treatment times and identify barriers at two Toronto hospitals: St. Michael’s Hospital (SMH) and Mount Sinai Hospital (MSH). Methods: Of all 797 patients diagnosed with CRC between January 1, 2005 and April 30, 2012 at SMH and MSH, 483 patients did not meet eligibility criteria. Thus, our sample population of 314 patients had stage II or III CRC, and received both surgical resection and AC at each respective hospital. Data collected included: time from surgery to first AC, patient demographics, and systemic/clinical barriers. Data was analyzed using statistical methods in Excel, assuming p-values <0.05 as significant. Results: The mean ageof the patients was 60.5 years (range 23 – 91); 55% were male and 72% had stage III disease; 75% (237/314) had colon cancer and 75% of AC was the FOLFOX regimen. The mean time from surgery to first AC was 57.4 days (sd = 16.8) or 8.2 weeks (range 4.1-18.7). Referral from surgeon averaged 20 days (sd=29.3). Time from medical oncology consult to first AC averaged 26.5 days (sd=30.8) including 23 days awaiting port-a-cath insertion. Post-operative medical complications affected 23.6% of patients. The presence of a complication was associated with delay in AC (10.6 days, p<0.001). An association between tumour site (eg. colon vs. locally advanced rectal cancer) and delay (p=0.0002) was also observed. Conclusions: Adherence to CCO guidelines can be optimized in CRC patients at SMH and MSH. The presence of a medical complication and tumour site are both factors associated with delays in AC treatment post-surgery. To improve the timeliness of care and achieve greater consistency between hospitals, rapid-cycle improvement of confounding barriers will be adopted.

Non-occupational post-exposure prophylaxis for HIV at St Michael's Hospital, Toronto: a retrospective review of patient eligibility and clinical outcomes

Stringent eligibility criteria, drug costs and antiretroviral toxicities are challenges in delivering HIV non-occupational post-exposure prophylaxis (nPEP). We reviewed patients' nPEP eligibility and clinical outcomes at St Michael's Hospital, Toronto, Canada to identify opportunities for improvement. Of 241 patients, 59%, 36% and 6% presented for high- (receptive anal/vaginal, blood), medium- (insertive anal/vaginal) and low-risk (oral) sexual exposures, respectively, and nearly all (93%) presented within 72 hours. Of 205 patients given nPEP, 20 were known to have discontinued nPEP prematurely: three due to costs but none due to toxicities. Two HIV seroconversions occurred in patients with suspected ongoing potential exposures. Five asymptomatic syphilis diagnoses were made among 71 tested. Only 39% and 19% of nPEP patients returned to our institution for follow-up at 3-4 and six months, respectively. Our findings underscore the feasibility and importance of nPEP programmes to HIV and sexually transmitted infection control, while identifying opportunities for improvement.

Editorial introductions

Editorial introductions

Regionalization of services improves access to emergency vascular surgical care

Management of vascular surgical emergencies requires rapid access to a vascular surgeon and hospital with the infrastructure necessary to manage vascular emergencies. The purpose of this study was to assess the impact of regionalization of vascular surgery services in Toronto to University Health Network (UHN) and St Michael's Hospital (SMH) on the ability of CritiCall Ontario to transfer patients with life- and limb-threatening vascular emergencies for definitive care. A retrospective review of the CritiCall Ontario database was used to assess the outcome of all calls to CritiCall regarding patients with vascular disease from April 2003 to March 2010. The number of patients with vascular emergencies referred via CritiCall and accepted in transfer by the vascular centers at UHN or SMH increased 500% between 1 April 2003-31 December 2005 and 1 January 2006-31 March 2010. Together, the vascular centers at UHN and SMH accepted 94.8% of the 1002 vascular surgery patients referred via CritiCall from other hospitals between 1 January 2006 and 31 March 2010, and 72% of these patients originated in hospitals outside of the Toronto Central Local Health Integration Network. Across Ontario, the number of physicians contacted before a patient was accepted in transfer fell from 2.9 ± 0.4 before to 1.7 ± 0.3 after the vascular centers opened. In conclusion, the vascular surgery centers at UHN and SMH have become provincial resources that enable the efficient transfer of patients with vascular surgical emergencies from across Ontario. Regionalization of services is a viable model to increase access to emergent care.

Time from surgery to first adjuvant chemotherapy: Experiences at an inner-city Canadian hospital.

527 Background: Cancer Care Ontario (CCO) guidelines advise that colorectal cancer (CRC) patients receive their first adjuvant chemotherapy (AC) no later than 8 weeks after surgical resection, with new data suggesting optimal treatment to commence between 4 and 6 weeks. This retrospective study was performed to determine treatment timelines and identify barriers at St. Michael’s Hospital (SMH). Methods: Of the 507 patients diagnosed with CRC between Jan 1, 2005 and May 1, 2012 at SMH, 304 patients had stage II or III CRC. Our sample population of 159 patients received both surgical resection and AC at SMH. Data collected included: time between surgery and first AC, patient demographics, systemic/clinical barriers and recurrence-free survival. Data was analyzed using SAS statistical software assuming p-values <0.05 as significant. Results: Of our 159 patients, mean age was 61.3 years (range 28 – 91); 54% male and 70% had stage III disease; colon cancer (64%) and mean follow-up was 2.2 years (range 0.1 – 5.7). Mean time from surgery to first AC was 50.4 days (sd = 15.8) or 7.2 weeks ranging from 3 to almost 17 weeks. Medical complications affected 21.4% of patients. The presence of a complication was associated with delay in AC (9.5 days, p=0.001). Moreover, 11.1% of patients were excluded from sample, since complications exceeded treatment past 12 weeks, equating to no AC. Referral from surgeon averaged 21 days (sd=12.0), 10 days awaiting pathology. Medical Oncology consult to first AC averaged 19 days (sd=12.7), 12 days awaiting port-a-cath insertion. Each part of referral process was correlated with delay to AC. Only 18.9% of patients recurred. While trends were identified, association between delay and recurrence was weak (p=0.1457). Medical complication correlated strongly with recurrence (p=0.0472). Patients with complications had a higher rate of recurrence (32.4% vs 15.2%). Conclusions: Compliance to current CCO guidelines can be optimized in CRC patients at SMH. Barriers to timely treatment include patient age, timely referral and presence of a medical complication. Quality improvement rapid cycling of confounding barriers will be used prospectively to lower variance and achieve greater consistency in treatment.

Chronic Stenotrophomonas maltophilia infection and mortality or lung transplantation in cystic fibrosis patients

Chronic Stenotrophomonas maltophilia infection is an independent risk factor for severe pulmonary exacerbations in cystic fibrosis (CF) patients. The goal of this study was to determine the effect of chronic S. maltophilia infection on mortality and the need for lung transplantation in a longitudinal study of children and adults with CF. This was a cohort study of CF patients from the Hospital for Sick Children and St Michael's Hospital (Toronto, Canada) from 1997 to 2008. A Cox Regression model was used to estimate the hazard ratio (HR) to time of death or lung transplantation adjusting for age, gender, genotype, pancreatic status, CF related diabetes (CFRD), forced expiratory volume in 1 s (FEV1), body mass index, number of pulmonary exacerbations, Pseudomonas aeruginosa, Burkholderia cepacia complex, Aspergillus and chronic S. maltophilia infection. A total of 687 patients were followed over the 12 year study period; 95 patients underwent a lung transplantation (of which 26 died) and an additional 49 patients died (total 144 events). In a Cox Regression model adjusting for baseline FEV1, baseline infection with B. cepacia complex (HR 1.72, 95% CI 1.09-2.71) and baseline chronic S. maltophilia infection (HR 2.80, 95% CI 1.65-4.76) were significantly associated with death or lung transplant. However, in a time-varying model, infection with B. cepacia complex and chronic S. maltophilia infection were no longer significant. Baseline chronic S. maltophilia infection is associated with an almost three-fold increased risk of death or lung transplant in CF patients. It is still unclear, however, whether chronic S. maltophilia infection is simply a marker of severity of disease and ultimate mortality or whether it is causally related to disease progression.

29B. Enhancing Primary Healthcare Delivery in the Inner City through Interprofessional Team-based Care

Focus Area: Sustainable Business ModelsThis session will describe the evolution of an integrative model of primary healthcare delivery within a hospital-based setting. Over the past decade, the Academic Family Health Team (AFHT) in the Department of Family and Community Medicine at St Michael's Hospital in Toronto has been in the business of transforming primary healthcare. The AFHT provides services to the inner-city community of Toronto through 5 clinical sites located conveniently in the downtown east core. Our model of care incorporates patient- and family-centered values; interprofessional collaboration; and accessible evidence-based care and research. Evaluation of our efforts has proved emancipating for both clinicians and patients—with the delivery of integrative healthcare services, improved coordination of care, enhanced patient outcomes and satisfaction, improved quality of work life for our health professional team, and patient/family empowerment in self-help strategies. This model of care was identified by the Council of the Federation Health Care Innovation Working Group as one of 4 innovative models of primary care delivery to be emulated in Canada. The session will describe our experiences in building our integrative healthcare team. Facilitators and barriers to the development of successful integrative models of primary care will be described. Specific strategies that have facilitated success in our experience also will be shared.

An Evaluation of a Proactive Geriatric Trauma Consultation Service

To describe and evaluate an inpatient geriatric trauma consultation service (GTCS). Delays in recognizing the special needs of older trauma patients may result in suboptimal care. The GTCS is a proactive geriatric consultation model aimed at preventing and managing age-specific complications and discharge planning for all patients 60 years or older admitted to the St Michael's Hospital Trauma Service. This was a before and after case series of patients admitted pre-GTCS (March 2005-August 2007) and post-GTCS (September 2007-March 2010). Study data were derived from a review of the medical records and from the St Michael's Hospital trauma registry. Abstracted data included demographics, type of geriatric issues addressed, rate of adherence to recommendations made by the GTCS, geriatric-specific clinical outcomes, trauma quality indicators, consultation requests, and discharge destinations. A total of 238 pre-GTCS patients and 248 post-GTCS patients were identified. The rate of adherence to recommendations made by the GTCS team was 93.2%. There were fewer consultation requests made to Internal Medicine and Psychiatry in the post-GTCS group (N = 31 vs N = 18, P = 0.04; and N = 33 vs N = 18, P = 0.02; respectively). There were no differences in any of the prespecified complications except delirium (50.5% pre-GTCS vs 40.9% post- GTCS, P = 0.05). Among patients admitted from home, fewer were discharged to long-term care facilities among the post-GTCS group (6.5% pre-GTCS vs 1.7% post-GTCS, P = 0.03). A proactive geriatric consultation model for elderly trauma patients may decrease delirium and discharges to long-term care facilities. Future studies should include a multicenter randomized trial of this model of care.

DASH work module in workers with hand-arm vibration syndrome

The Disabilities of the Arm, Shoulder and Hand work module (DASH-W) questionnaire has not previously been described in relation to hand-arm vibration syndrome (HAVS). To measure work-related disability in workers with HAVS using the DASH-W questionnaire and to determine how the various components of HAVS affect the DASH-W score. Workers with HAVS from a variety of industries were assessed over a 2-year period at the occupational health clinic, St Michael's Hospital, Toronto. Subjects completed the DASH-W questionnaire and were assessed by an occupational physician to determine their Stockholm sensorineural and vascular stages and upper extremity pain score measured by the Borg scale, as an indication of musculoskeletal problems associated with HAVS. The average DASH-W score was compared with the average value for the US population. Multiple linear regression was used to determine the contribution of the various components of HAVS to the DASH-W score. There were 139 (134 men and 5 women) participants. The subjects with HAVS had a mean DASH-W score of 54.7 (95% CI: 50.3-59.1), which was considerably higher than the average for the US population (P < 0.001). Statistically significant HAVS variables in the multiple linear regression included the Stockholm sensorineural stage (P < 0.05) and the upper extremity pain score (P < 0.001) with the pain score having the highest partial R (2) value. Workers with HAVS reported significant upper extremity work-related disability as measured by the DASH-W questionnaire, and the upper extremity pain score made the largest contribution to the DASH-W scores in these subjects.

Diet Order Entry by Registered Dietitians Results in a Reduction in Error Rates and Time Delays Compared with Other Health Professionals

In January 2009, registered dietitians (RDs) at St Michael's Hospital (Toronto, Ontario, Canada) were granted approval for nonmedication order entry of physician-approved nutrition-related orders for the patients to whom RDs provided care. The aim of this project was to document any changes in the numbers and types of diet order errors and time delays that were associated with this policy change. A retrospective chart audit was conducted to document the error rate in 672 nutrition-related orders placed before, and in 633 orders placed after, implementation of RD diet order entry on high-risk inpatient units. Error rates for all nutrition-related orders decreased by 15% after RD order entry access (P<0.01). Error rates for diet orders entered by RDs were significantly lower in comparison with those entered by clerical assistants or registered nurses (P<0.001). Time delays for orders electronically entered were reduced by 39% (from 9.1 to 5.7 hours; P<0.01). Allowing RDs access to the electronic order entry system has improved overall timeliness of nonmedication order entries and improved patient safety by decreasing error rates in diet orders. This study supports this institutional policy change and provides evidence that RDs have the knowledge and skills to accurately process nonmedication order entries for the patients they have assessed. Finally, the current findings support the need for ongoing education and training of all health professionals in nonmedication order entry to reduce errors and improve safety.

Neonatal outcomes for pregnancies affected by haemolytic disease of the fetus and newborn and managed with intrauterine transfusion

IntroductionThis study was conducted within the tertiary Fetal Medicine Unit (FMU) at St Michael's Hospital (StMH), Bristol. The first aim was to provide improved information regarding neonatal outcomes for parents...

Editorial introductions

Editorial introductions

The role of HDL and its modulators in the development of diabetes

aKeenan Research Centre, Li Ka Shing Knowledge Institute, Department of Medicine, St Michael's Hospital bDepartment of Physiology, Faculty of Medicine cDepartment of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada Correspondence to Dominic S. Ng, PhD, MD, Keenan Research Center, St. Michael's Hospital, Shuter Wing Room 3-041, 30 Bond Street, Toronto, ON, Canada M5B1W8. Tel: +1 416 864 5197; fax: +1 416 864 5584; e-mail: [email protected]

The Evolving Utility and Emergent Uses of Novel Lipid Emulsions

Journal of Parenteral and Enteral NutritionVolume 36, Issue 6 p. 626-629 Invited Commentaries The Evolving Utility and Emergent Uses of Novel Lipid Emulsions New Horizons and Rediscovered Prospects Brian Jurewitsch PharmD, Corresponding Author Brian Jurewitsch PharmD [email protected] St Michael's Hospital, University of Toronto, Ontario, CanadaBrian Jurewitsch, PharmD, St Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada; e-mail: [email protected].Search for more papers by this author Brian Jurewitsch PharmD, Corresponding Author Brian Jurewitsch PharmD [email protected] St Michael's Hospital, University of Toronto, Ontario, CanadaBrian Jurewitsch, PharmD, St Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada; e-mail: [email protected].Search for more papers by this author First published: 27 March 2012 https://doi.org/10.1177/0148607112441625Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume36, Issue6November 2012Pages 626-629 RelatedInformation

Non-alcoholic fatty liver disease and outcomes in persons with acute coronary syndromes: insights from the GRACE-ALT analysis

ObjectiveNon-alcoholic fatty liver disease (NAFLD) is associated with a higher risk of cardiovascular disease, but no data exist about the relation between NAFLD and adverse outcomes in persons with acute...

P1-11-13: Improvement in the Quality of Care for Patients with Locally Advanced Breast Cancer through Implementation of an Integrated Electronic Care Pathway.

Abstract Background: Locally advanced breast cancer (LABC) refers to the most advanced stage of non-metastatic tumours with an incidence of approximately 10% in newly diagnosed breast cancers. Currently, for optimal care, patients with LABC require a multidisciplinary approach including coordinated planning with medical, surgical and radiation oncologists. Many barriers may exist in co-ordinating timely management of these patients. Care pathways are important tools to streamline care and data collection and feedback allows for quality improvement in clinical practice. We created an interactive electronic care pathway and self populating quality assurance database at St. Michael's Hospital (SMH) to facilitate multidisciplinary teams to track LABC patient histories and patient treatments in order to coordinate therapy effectively and expedite care (LABC E-PATH). Methods: This is an observational before-and-after cohort study of patients with LABC with a retrospective review pre-implementation and prospective collection of clinical data post-implementation. The completeness of workup and the timeliness of treatment pre- and post-implementation were assessed. Results: With the implementation of the LABC E-PATH in May 2010, the time between the referral of an LABC patient to a medical oncologist and consultation has decreased from 7 days (range 0 to 493) pre-implementation to 2 days (range 0 to 29) post-implementation. The time between referral to medical oncologist and the start of their chemotherapy treatment decreased significantly from a median of 19 days to 8 days (pre-implementation: range = 0 to 493, postimplementation: range = 0 to 128) (p=0.0028). All pre-treatment staging was completed faster post-implementation of the LABC e-path than pre-implementation, expediting time to initiation of chemotherapy. The number of referrals for LABC to the SMH program increased from &amp;lt; 1 patient per month to 4 patients per month post-implementation. Conclusions: The LABC E-PATH has achieved its goal of expediting care and overcoming barriers to timely treatment in this patient population. It has also ensured timely and appropriate resource allocation. This unique system may also be applied to other disease sites where coordination of a multi-disciplinary team is critical for appropriate patient management. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-11-13.

Improvement in the quality of care for patients with locally advanced breast cancer through implementation of an integrated electronic care pathway.

207 Background: Locally advanced breast cancer (LABC) refers to the most advanced stage of non-metastatic tumours with an incidence of approximately 10% in newly diagnosed breast cancers. Currently, for optimal care, patients with LABC require a multidisciplinary approach including coordinated planning with medical, surgical and radiation oncologists. We created an interactive electronic care pathway and self populating quality assurance database at St. Michael’s Hospital (SMH) to facilitate multidisciplinary teams to track LABC patient histories and patient treatments in order to coordinate therapy effectively and expedite care (LABC E-PATH). Methods: This is an observational before-and-after cohort study of patients with LABC with a retrospective review pre-implementation and prospective collection of clinical data post-implementation. The completeness of workup and the timeliness of treatment pre- and post-implementation of the LABC E-PATH in May 2010 were assessed. Results: With the implementation of the LABC E-PATH in May 2010 at SMH, the delay between the identification of the patient as LABC and their referral to a medical oncologist for treatment for their LABC decreased from a median of 9 days pre-implementation, (range 0-780 days) to 1 day post-implementation, (range 0-52 days). The time between referral to medical oncologist and the start of their chemotherapy treatment decreased from a median of 12 days to 9 days (pre-implementation: range = 4 to 494, post-implementation: range = 0 to 39). All pre-treatment staging was completed faster post-implementation of the LABC e-path than pre-implementation, expediting time to initiation of chemotherapy. The number of referrals for LABC to the SMH program increased from &lt; 1 patient per month to 5 patients per month post-implementation. Conclusions: The LABC E-PATH at SMH has achieved its goal of expediting care for this patient population. It has also ensured timely and appropriate resource allocation. This unique system may also be applied to other disease sites where coordination of a multi-disciplinary team is critical for appropriate patient management.

Management and outcome of vasa praevia in a teaching hospital over a 10 year period

IntroductionRCOG have recently published guidelines regarding vasa praevia. Routine screening is not recommended but additional ultrasonography is advised if vasa praevia is suspected from previous ultrasound scans or clinical suspicion....

Improvement in the quality of care for patients with locally advanced breast cancer through implementation of an integrated electronic care pathway.

e16580 Background: Locally advanced breast cancer (LABC) refers to the most advanced stage of non-metastatic tumours with an incidence of approximately 10% in newly diagnosed breast cancers. Currently, for optimal care, patients with LABC require a multidisciplinary approach including coordinated planning with medical, surgical and radiation oncologists. We created an interactive electronic care pathway and self populating quality assurance database at St. Michael’s Hospital (SMH) to facilitate multidisciplinary teams to track LABC patient histories and patient treatments in order to coordinate therapy effectively and expedite care (LABC E-PATH). Methods: This is an observational before-and-after cohort study of patients with LABC with a retrospective review pre-implementation and prospective collection of clinical data post-implementation. The completeness of workup and the timeliness of treatment pre- and post-implementation of the LABC E-PATH in May 2010 were assessed. Results: With the implementation of the LABC E-PATH in May 2010 at SMH, the delay between the identification of the patient as LABC and their referral to a medical oncologist for treatment for their LABC decreased from a median of 9 days pre-implementation, (range 0-780 days) to 1 day post-implementation, (range 0-52 days). The time between referral to medical oncologist and the start of their chemotherapy treatment decreased from a median of 12 days to 9 days (pre-implementation: range = 4 to 494, post-implementation: range = 0 to 39). All pre-treatment staging was completed faster post-implementation of the LABC e-path than pre-implementation, expediting time to initiation of chemotherapy. The number of referrals for LABC to the SMH program increased from < 1 patient per month to 5 patients per month post-implementation. Conclusions: The LABC E-PATH at SMH has achieved its goal of expediting care for this patient population. It has also ensured timely and appropriate resource allocation. This unique system may also be applied to other disease sites where coordination of a multi-disciplinary team is critical for appropriate patient management.

The Manometric Finding of Inclusion Body Myositis

Background: Zenker diverticulum (ZD) is a lesion most often seen in elderly patients. The traditional treatment is surgical but recently endoscopic septoplasty has been described as an alternative approach, especially in high surgical risk patients. We aimed to determine the efficacy and safety of flexible endoscopic septoplasty (FES) for symptomatic ZD. Methods: Retrospective review of all patients who underwent FES for ZD over the previous 5 years at St Michael's Hospital, Toronto were identified. Patient charts were reviewed to record patient demographics, procedure technique, operative times, sedation requirements, and complications. Patients were contacted via telephone to establish postoperative symptoms within 12 months of treatment and to evaluate current symptoms using a validated dysphagia score from 0 (no dysphagia) to 4 (complete dysphagia) and overall symptoms in terms of complete/near complete response, moderate response and complete recurrence. Results: Forty-three patients underwent FES between 2005 and 2010. The median age was 75 years (IQR 68-83). Twenty-nine (67.4%) were male. The mean (range) ZD size was 3.0cm (1 5cm). All patients were treated on an outpatient basis. A total of 90 procedures were performed, with a median of 2 procedures (IQR 1-3) per patient. Procedures were performed with conscious sedation in 88 (97.8%) cases, with median sedation requirements of 3mg (IQR 3-6) of midazolam and 100mcg (IQR 87.5-100) of fentanyl. The mean procedure time was 34 minutes (range 10 65). Thirty patients were contactable to assess response to therapy. Within 12 months of the initial therapy, 15 (50%) had complete/near complete symptom resolution, 10 (33.3%) moderate symptom improvement and 5 (16.7%) complete symptom recurrence. Following retreatment in the latter two groups, at a mean follow-up of 13.5 months, 2 (13.3%) had complete/near complete symptom resolution, 9 (60%) moderate symptom improvement and 3 (20%) complete symptom recurrence. Complications included 2 perforations (one requiring surgical drainage of a neck abscess); 2 cases of minor bleeding and 1 patient admitted with fever post procedure (perforation excluded on imaging). Mean admission duration was 7.8 days (range 1-13). Conclusion: (i) FES using needle-knife papillotome is a safe and effective therapy for ZD. (ii) FES should be considered in patients in whom surgery is considered high-risk or technically difficult. (iii) Repeat FES in poor responders is effective and safe (iv) Further studies to refine this technique are required to improve symptoms. Acknowledgment S.R. has been supported by a UWA Medical Research fellowship and the Faculty of Medicine, Dentistry and Health Sciences in Perth, Western Australia.