Winter 2014

Dying for a good night’s sleep

LHSC’s Sleep and Apnea Assessment Unit

Team Canada’s Kaya Turski

An Olympian against the odds

A look at hospital capacity challenges

The changing face of cancer treatment New treatment options for head and neck cancer

Suite serenity for travelling cancer patients

Dr. Bob Litchfield (above) who treated Turski, also served as the Chief Orthopaedic Surgeon for the Canadian Alpine Ski Team at the Olympics this February.

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02 An Olympian against the odds Just six months before the Winter Olympics, Kaya Turski, the number one ski slopestyle competitor in the world suffered a debilitating knee injury. Learn about the innovative surgery performed by LHSC’s Dr. Bob Litchfield that saved her Olympic Dream.

04 Did you know? For over 50 years, a free accommodation service provided by LHSC’s London Regional Cancer Program has made the journey through cancer easier for out-of-town patients.

05 Dying for a good night’s sleep As one of LHSC’s Sleep and Apnea Assessment Unit’s first patients, Jerry Lee discovered that sleep apnea was not only robbing him of his rest – it also threatened to kill him. Over the next 25 years, Lee and his health-care team at LHSC embarked on a journey to save his life.

07 Making room A look at the challenges faced by the hospital – and how discharge planning helps to get the right patient in the right bed at the right time.

11 The changing face of cancer treatment Rod Sinn was living the life of his dreams until a startling discovery of cancer threatened to end it all. Using the da Vinci surgical robot, LHSC’s Dr. Kevin Fung and Dr. Anthony Nichols provided a new treatment option.

13 Decoding the elements for a cure New research led by Lawson Health Research Institute’s Dr. Richard Kim shows that for estrogen receptor positive breast cancer – one treatment doesn’t fit all.

14 On the Scene at LHSC See what we’ve been up to since our last issue.

15 You asked us What are some tips for a good night’s sleep?

Contents

Who We AreOne of Canada’s largest acute care teaching hospitals,

London Health Sciences Centre (LHSC) cares for the

most critically ill patients in the region. Located in London,

Ontario, Canada, LHSC encompasses:

• University Hospital• Victoria Hospital• Children’s Hospital

LHSC is the home of:

• CSTAR (Canadian Surgical Technologies and Advanced Robotics)

• Fowler Kennedy Sport Medicine Clinic

• London Regional Cancer Program

• Children’s Health Research Institute

• Lawson Health Research Institute

• Children’s Health Foundation

• London Health Sciences Foundation

inside.lhsc.on.caYour feedback is important to us – please visit inside.lhsc.on.ca to complete the survey.

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ON THE COVER: LHSC’s Sleep and Apnea Assessment Unit staff monitor a sleep study. Turn to page five to go inside Jerry Lee’s personal experience as a Sleep and Apnea Assessment Unit patient.

• Byron Family Medical Centre• Victoria Family Medical Centre• Kidney Care Centre

(at Westmount Shopping Centre)

Slopestyle skier Kaya Turski was at the top of her game – until a serious injury threatened to ground her Olympic dream. Take an in-depth look at the innovative surgery performed by LHSC’s Dr. Bob Litchfield that helped her compete in Sochi.

When the International Olympic Committee announced that slopestyle skiing would make its debut as an official sport at the 2014 Winter Olympics in Sochi, Russia, Canadian freestyle skier Kaya Turski – the number one ski slopestyle competitor in the world – received a dream opportunity to represent her country on the inaugural Canadian team.

But last August, less than six months away from the Winter Games, Turski sustained a debilitating knee

injury. While training to master a new move called a “switch 720,” which involves taking off from a backwards position and completing two 360-degree rotations in the air, Turski was caught by surprise by the landing. The force of gravity coupled with the torque from her mid-air spins proved too much for her legs to bear. Turski instantly knew that the anterior cruciate ligament (ACL) in her left knee had torn apart. “I just knew it right away,” she says. “I blew it.”

Under normal circumstances, recovery from an ACL injury stretches from seven to 10 months or longer. Making matters more complicated, Turski had sustained this injury before. This meant that the normal means of repairing the ACL – using a graft from her own hamstring tissue and running it through tiny holes drilled in her bones – could not be performed again. She didn’t have any tissue left to donate for a second surgery and a synthetic ACL was too narrow to fill the holes where the first graft had been.

It was on recommendation from a fellow athlete that Turski turned to LHSC’s Dr. Bob Litchfield, Orthopaedic Surgeon and Medical Director of the Fowler Kennedy

Sport Medicine Clinic. Dr. Litchfield has treated several Olympians, including skiers Jan Hudek, Erik Guy and Larisa Yurkiw.

Working on Turski’s injury would be complicated. “When you are revising a surgery, it’s always a challenge because you have to work around what’s already been done.

An Olympian against the odds

Just six months before the 2014 Winter Olympics, a torn anterior cruciate ligament (ACL) threatened to end Kaya Turski’s dream of competing as part of the Canadian Olympic team in Sochi, Russia.

Photo credit: Anna van Welij.

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There are only so many holes you can drill,” says Dr. Litchfield. “Because of previously drilled holes, a synthetic ACL [for Turski] would have rattled around in the joints like a mop in a bucket without donor tissue to protect it.”

Together, doctor and patient devised a course of treatment to provide Turski with a functioning knee that would last not only through the Olympics, but for the rest of her life.

In late August, Dr. Litchfield performed an innovative surgery on Turski – replacing her torn ligament with a synthetic ACL wrapped in tissue from an outside donor. The synthetic ACL, which is made from industrial strength polyester, provided instant strength while the donor tissue allowed the ligament to fit snuggly.

While Turski could bear weight on her knee immediately after surgery, she still had a lot of work to do. Rehabilitation

included 15-20 hours in the gym each week, followed by training on the trampoline before she could touch snow.

By December, only a few short months after surgery, she was on the slopes again and full of enthusiasm.

On January 17, Turski competed in the Grand Prix in Utah, and even though she had little time to train on the course, she placed on the podium, proving that she was back in competitive form. Then, on January 25, only one week after

competing in Utah, she captured her fifth Winter X Games gold medal. When asked how her knee was fairing, Turski said that she was “feeling really good.”

When Turski competed on Feb.11 in Sochi, Dr. Litchfield was not far away – as the Chief Orthopaedic Surgeon for the Canadian Alpine Ski Team. He was one of three Fowler Kennedy Sport Medicine Clinic representatives who volunteered their time to be part of an official Canadian medical team, which provides athletes with care for any injuries, whether minor or serious.

At the end of the day, Turski’s success at the Olympics would have nothing to do with medal standings – but simply in the ability to compete in the sport that she loves.

Though she was disappointed not to take the podium, Turski still had a lot to celebrate. “I’ve worked so hard, I poured my heart and soul into the last six months,” she said. “I think I did an incredible thing just dropping in. I’m proud to say I’m an Olympian now.”

Dr. Litchfield says it is important to take care of Canadian athletes, no matter their standing, because they represent our country. “We have great respect for what they do and if you can make their recovery from injury that much easier, that’s the least we can offer.”

One of the leading sport medicine clinics in North America, the Fowler Kennedy Sport Medicine Clinic has a long history with the Olympics.

At a time when official Olympic medical teams did not exist, clinic co-founder – the late Dr. J.C. Kennedy – made history when he initiated the development of the Canadian Academy of Sport and Exercise Medicine (CASEM), which was mandated to provide medical care to our athletes. He later went on to lead the first official Canadian Olympic medical team, over 30 years ago.

Since then, several clinic staff members have volunteered their time as part of official medical teams at key global events.

Clinic co-founder Dr. Pete Fowler has travelled far and wide as part of a medical team, attending the Pan Am games, Commonwealth Games and the 1984 Winter Olympics in Sarajevo, Yogoslavia as the Chief Medical Officer.

“It’s busy,” says Dr. Fowler of working on a medical team. “When you’re at an event with a lot of team sports, you have to supply coverage for those sports as well as keep the clinic going. For our athletes, there are a lot of problems that

would seem little in an ordinary life that are very big before a major competition.”

According to Dr. Litchfield, the Fowler Kennedy Sport Medicine Clinic has a great reputation and attracts high-caliber athletes not only because of the expertise of the staff and physicians, but also because of the unique level of personal care and attention patients receive.

The Fowler Kennedy Sport Medicine Clinic – A rich history of supporting our Canadian athletes

Only a few months after surgery, Kaya Turski once again captured gold at the Winter X Games.

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Go inside Kaya Turski’s

video journal at inside.lhsc.on.ca

DID YOU KNOW

London Regional Cancer Program patients enjoy socializing in the dining room at the Marriott Residence Inn, where they have been provided with free accommodation. Suite serenity – a new partnership provides a home away from home for cancer patients

Having cancer is tough enough – and when you have to travel far from home to receive treatment it can be even more challenging. So for more than 50 years, funding from the Ministry of Health and Long-Term Care has provided free accommodation in London for cancer patients who travel 40 kilometers or more to receive chemotherapy and radiation treatment at London Health Sciences Centre’s London Regional Cancer Program (LRCP).

Since 1962, LHSC’s Thameswood Lodge proudly served as this home away from home, but when the South Street Hospital property was repatriated to the City of London earlier this year, a new location had to be found to serve the approximately 1,000 patients who take advantage of the service each year.

“It was important for LHSC to take this challenge and turn it into an opportunity,” says Neil Johnson, Vice President, Cancer Care, LHSC. “A key objective from the outset was to consult extensively with patients and families who had used Thameswood to fully understand their needs and preferences with respect to such services and to use that input to shape our criteria for any new provider.”

The call for a new site and services was one that the Marriott Residence Inn was more than happy to answer. After placing a bid in response to LHSC’s request for proposals, the hotel was selected as the new provider of the service.

Winning attributes of the hotel included its accessible and centralized location along with its ability to provide the amenities that patients and family members deemed most valuable.

To optimize the hotel to meet specific patient/client needs, the Residence Inn, with the assistance of LHSC, increased the

number of wheelchair parking spaces, became a scent-free work environment and added a supply of medical assistive devices such as walkers, oxygen tanks, wheelchairs, shower chairs, canes, seats, sitz baths, and sharps containers.

Hotel policies were also revised in order to better accommodate patient’s schedules. Guests who are patients of LRCP may now check in as early as 7:30 am and check out as late as 4 pm. Those who wish to extend their stay into the weekend can do so at a reduced rate.

A shuttle service, which is provided by the hospital, transports patients to and from the Residence Inn and LRCP.

“When we received the opportunity to place the bid, we got together as a team and the buy-in was instantaneous,” says Anna McNutt, General Manager of the Residence Inn.

According to McNutt, feedback from patients has been positive and they have received many comments.

“In terms of handing over the torch, we’re happy that the transition was smooth for patients,” says Julie Sans, Cancer Support Services Coordinator. “At the Residence Inn, you have caring staff, the spacious environment and lots of amenities. Patients are going to be looked after—they’re not just a hotel guest.”

More about the accommodation serviceFree accommodation is available to patients who are actively receiving chemotherapy or radiation treatment at least 40 kilometers away from home, and are able to look after themselves (e.g. able to wash, dress, and get their own meals).

Patients can become hotel guests by calling the Radiation Therapy area in LRCP at 519-685-8656 to make a reservation, followed by completing a form.

Patient amenities at the Residence InnThe Residence Inn provides a wealth of amenities to patient guests, including:

• Free Wi-Fi

• Fitness centre

• Free access to the YMCA

• Grocery shopping service

• Daily dry cleaning service

• On-site coin laundry

• A 24/7 food and beverage pantry

• Business centre with computers, internet access, a fax machine and free local calls

• A common room, called the Thameswood Room, which promotes an ongoing sense of community among patients, who often find support and friendship in their fellow travelling patients

• Wellspring Cancer Support Centre close by and easily accessible

Each patient suite at the Residence Inn has:

• A sitting area

• A kitchen

• A washroom (which can be fitted with assistive devices if needed)

• Two queen-size beds

• Televisions in the bedroom and sitting area

“The staff bend over backwards for anything I need, over and over again.” – Anonymous patient

“The rooms are so spacious, bigger than I have at home.” – Anonymous patient

“Staff are so passionate and caring.”

– Anonymous patient

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The year was 1988. Jerry Lee was only 30 years old and he couldn’t stay awake to save his life.

“I couldn’t sit down to watch TV without falling asleep,” he says. “But I did a lot of physical outdoor work and thought I was falling asleep because I was tired.”

As time went on, it became clear that the extreme fatigue was a product of more than physical exertion. His wife noticed that Lee wasn’t sleeping well. While Lee couldn’t remember doing so, she saw him jolt awake several times throughout the night.

Assessment at St. Thomas Hospital suggested that Lee had sleep apnea, but to confirm the diagnosis he was sent for overnight observation at the newly opened Sleep Clinic at

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About the Sleep and Apnea Assessment Unit at LHSCThe Sleep and Apnea Assessment Unit at London Health Sciences Centre – Victoria Hospital (formerly located at South Street Hospital) provides consultation, diagnosis and sleep study testing for adults (age 18+) for over 50 known sleep disorders, including:

• Insomnia

• Restless leg syndrome

• Narcolepsy

• REM sleep behavior disorders

• Circadian rhythm disorders

• Sleep apnea

• Disturbed sleep

• Hypersomnia (excessive daytime sleepiness)

• Parasomnia (e.g. inappropriate actions during sleep, such as sleep walking, night terrors, etc.)

When to seek helpReferral to the Sleep and Apnea Assessment Unit is made through primary care providers or family physicians. You may wish to seek help if you experience:

• Excessive daytime sleepiness – falling asleep at inappropriate times or dangerous times during the day (e.g., driving)

• Disturbed sleep (often noticed by a partner, including loud snoring, adult sleep walking, etc.)

• A restlessness in your legs that occurs in the evening hours

• Persistent difficulty falling asleep or inability to stay asleep through the night and it’s affecting your ability to function during the daytime

• Physically acting out dreams, which can be a symptom of a sleep behaviour disorder

• Feelings of depression and anxiety due to lack of sleep.

See our “You asked us” section on the back page for tips on getting a good night’s sleep.

London Health Sciences Centre (LHSC) – marking the start of his long journey of care with Respirologist, Dr. Charles George.

“They hook you up with over 20 wires and glue electrodes onto your body,” he says of his experience staying overnight in the sleep clinic. But in just one night, the results were clear. “Dr. George told me that I had one of the worst cases of sleep apnea he’d ever seen.”

In fact, the tests showed that Lee’s breathing stopped every 50 seconds.

Sleep apnea is a sleep disorder characterized by pauses in breathing that can occur several times every minute. Many people with sleep apnea are not even aware that they are having difficulty breathing. The number one factor contributing to the development of sleep apnea is excess weight, which puts pressure on the airway, though anyone with a small upper airway may suffer from the condition as well.

Dr. George is quick to point out that the impact of poor sleeping goes beyond just the immediate issue of breathing. “You really have to look at sleep as having far-reaching effects on overall health. Quality of sleep can have a dramatic effect on quality of life,” he says.

“The heart becomes strained when there is apnea,” explains Dr. George. “When we stop breathing, the body still continues to use the oxygen it has – it just isn’t being replenished. That leads to oxygen deprivation, known as hypoxia, which places strain on the cardiovascular system as blood vessels constrict, resulting in a significant deterioration of one’s health condition. Patients face increased risk of high blood pressure, stroke, atrial fibrillation, congestive heart failure and ultimately, death.”

Because of the far-reaching implications of sleep quality, the field of sleep apnea and treatment has become multi-disciplinary, often involving ear, nose and throat specialists, dentists, maxillofacial surgeons (i.e. surgeons who work on the head, neck, face, jaws and mouth) and psychologists.

In Lee’s case, the first course of treatment was outfitting him with a continuous positive airway pressure device or CPAP machine. The machine keeps the airway open by delivering a stream of compressed air through a facemask. After just one night of sleep with the CPAP machine Lee felt well-rested.

Unfortunately, over the coming years, Lee’s condition deteriorated. Lee discovered he was diabetic and struggled with weight gain associated with insulin injections. Then a bout of illness caused him to gain even more weight and the CPAP machine no longer provided relief. He tried a Bi-PAP machine, which delivers different levels of pressurized air depending on whether Lee was breathing in or out, but over time, even that machine could not sufficiently open his airway to provide the steady breathing required for uninterrupted, restful sleep.

Lee’s sleep apnea caused such extreme daytime sleepiness that he had to give up driving so that he would not pose a danger on the road.

In 2011, at 53 years old, Lee’s heart began to show signs of failure due the stress of oxygen deprivation. He could barely walk and had to be on oxygen continually.

Dr. George advised Lee that the only way to save his life was to lose weight. Bariatric surgery – or weight loss surgery – was the best course of action, but before Lee’s body could sustain the strain of being put under anesthetic, he had to be stabilized. A tracheostomy – a tube inserted in his trachea – allowed him to breathe freely once more and his body became strong enough to undergo surgery within the year.

The bariatric surgery was a success and resulted in substantial weight loss.

Today, Lee is well rested and on the road to better health. Not only is he walking, he’s able to exercise. He no longer needs insulin to manage his diabetes, and while he still sleeps with a CPAP machine, the amount of pressure needed to keep his airway open has been substantially reduced.

In regards to his new lease on life, Lee credits the help he received from Dr. George, who has tracked Lee’s overall health-care journey for more than 25 years.

“I’d recommend Dr. George to anybody,” he says. “If it hadn’t been for the care I received, I wouldn’t be alive today – I know that.”

In 1988, Jerry Lee became one of the first patients of

LHSC’s Sleep and Apnea Assessment Unit. Over the coming

decades, with the help of LHSC’s Dr. Charles George,

Lee would wage a winning battle against sleep apnea,

to win back his breath, his sleep, and ultimately, his life.Go to inside.lhsc.on.ca to take a video tour of the Sleep and Apnea

Assessment Unit

Dying for a good night’s sleep

Jerry Lee demonstrates how the CPAP machine provides continuous airflow in order to help treat sleep apnea.

Jerry Lee’s CPAP machine. Technicians monitor patients from the control area in the Sleep and Apnea Assessment Unit.

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Why isn’t there always a bed available?As one of Canada’s largest acute-care teaching

hospitals and a regional referral centre, LHSC provides patient care for approximately 150,000 emergency visits, 50,000 admissions and more than 15,000 operating room inpatients each year. With these volumes, LHSC and other large reginal acute-care hospitals are consistently over capacity and unfortunately patients who need to be admitted can spend hours—sometimes days—waiting for a bed to become available.

In order to keep a hospital running smoothly, an equal focus must be placed both on getting patients admitted and on discharging those who no longer need acute-care.

Discharge planning, which helps move patients back home or to alternative levels of care, involves many considerations and is an important piece of the health-care puzzle. Ideally, it helps guide patients down the road to recovery and predicts the next available opening for the next patient in need, but discharge planning is a multi-faceted process subject to frequent change by forces both in and out of the hospital’s control.

Why is it so hard to figure out when a patient will leave the hospital?

Health-care teams are skilled at assessing patients to determine when they will likely be ready to leave the hospital. This helps the hospital to know the number of beds available for admission at any given time, and whether or not the anticipated available beds will be sufficient to support current patient volumes.

While the process of predicting discharge is robust, each patient is unique and each discharge plan is adapted daily according to the patient’s condition and readiness to go home.

LHSC is an acute-care facility, meaning that resources are optimized to provide urgent care for patients with severe injuries or illnesses. Acute-care facilities are not intended to provide long-term care, and patients are discharged as soon as they are considered healthy enough to return home or to be transferred to another facility.

In any health-care journey, there are many factors that can change the anticipated discharge time and date. An anticipated discharge date may be adjusted based on a patient’s condition – but it may also be affected by other factors. A simple miss in communication, or a seemingly innocent delay in picking a family member up from the hospital can quickly domino into delays in discharging patients who are well enough to leave.

I’ve heard of patients being placed in beds stationned in hallways – why does this happen?

When patient volumes surge above the hospital’s capacity, LHSC makes the most of all available space in order to care for patients in a timely manner. This may mean that some patients are placed in ‘non-traditional space,’ which encompasses placing a fifth bed in a four-bed room, cohorting male and female patients, retaining patients in the Post-Anesthesia Care Unit (PACU), keeping temporary spaces like the Decant Unit open 24 hours or placing patients under supervision in hallways and conference rooms.

To free up a valuable inpatient bed, those who have been cleared for discharge the following day may be given the option to leave earlier, for instance, on the evening before their designated discharge date. This often works better for family members who work during the day as they can pick up their loved ones from hospital in the evening.

As a patient at LHSC, how do I know what my progress is and when I’ll be going home?

From the moment a patient is admitted, the health-care team is focused on the road to recovery. All new patients receive a discharge letter that outlines their anticipated check-out time and requests their assistance with their discharge. While many are surprised to receive the letter, it is an important tool the health-care team uses to help prepare the patient and provide information on their length of stay.

Many strategies are used to track a patient’s daily progress. For example, each day, the health-care team meets for “bullet rounds” where they discuss:

• What is the patient’s medical status?• What is the patient’s functional status (i.e. ability

to perform normal daily activities required to meet basic needs)?

• What is the discharge goal?• What is today’s medical/functional plan to reach the

discharge goal?• What is the confirmed discharge plan and date

of discharge?This information is communicated to patients in a

number of ways, including whiteboards that are placed in the patient’s room, which outline their status and their next health-care goal. The board is updated daily and is discussed during nursing bedside reporting, which occurs at shift change. Incoming and outgoing nurses will talk

to the patient and their family about their goals, progress and discharge plan.

In addition, patients can monitor their progress towards discharge through “stoplight” signage placed on their whiteboard, where:

LHSC has designated “check-out” times at 11 a.m. and 2 p.m. Sometimes, in order to better serve those with the highest need, those who have been cleared for discharge may be asked to wait in a common area for their ride. The patient always has the right to refuse, but in moving out of the bed when they are strong enough to do so, it frees that bed for the next patient needing acute-care.

I’ve heard that some patients are discharged only to return to acute-care at a later date. What are you doing to ensure this doesn’t happen?

The health-care team’s aim is to ensure that all patients have the tools and resources they need to continue their recovery outside of the hospital’s walls.

While some patients may be readmitted due to changes in their condition, other returns to acute care are driven by patient questions and concerns regarding their recovery. Encouraging patient education, increasing access to resources are strategies aimed at increasing understanding of what is a normal part of recovery, and when a return to acute-care is medically necessary.

To help address additional concerns after discharge, LHSC has initiatives aimed at providing helpful information and resources outside of the hospital walls. Online hospital resources for the public are available to help answer patient’s frequently asked questions, with the hope of preventing the need for patients to return to the hospital.

In addition, initiatives are being developed to address the concerns of specialized patient populations. For instance, the Department of Orthopaedics has embarked on a pilot project to determine if performing follow-up phone calls to track patient progress and answer any questions, results in fewer return visits to the hospital.

Red = discharge greater than 72 hours

Yellow = discharge within 72 hours

Green = discharge within 24 hours

SLEEP APNEADISCHARGE PLANNING

Making roomInside hospital capacity challenges – and how

discharge planning is helping to get the right

patient to the right bed at the right time.

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Imagine arriving at the Emergency Department in need of immediate medical care. Waiting on a stretcher, you are told that you will need to be admitted for additional care, but unfortunately, there are no beds available – and not just on the unit you need, but anywhere in the hospital. So you wait.

As part of the team responsible for ensuring the right patient goes to the right bed at the right time, striking the delicate balance between admission and discharge is a challenge that Pat Jewell, LHSC’s University Hospital Bed Management Coordinator, knows all too well.

“It’s all about discharging patients safely into the best place for those individuals, while at the same time addressing that we’re over capacity,” says Jewell.

She sits in front of three computer screens: one for everyday business; a second for logging calls between physicians throughout the region who are hoping to connect patients with resources at LHSC; and a third to keep an ever-watchful eye over the constantly changing status of bed space in each and every corner of the hospital.

On this third screen is a constantly moving series of colour coded labels, arranged in columns representing each hospital unit. Beds that contain patients who have been confirmed for discharge, as well as those who may be ready for discharge, are labelled in pink and blue (to indicate female or male). A yellow label shows a bed that has been recently vacated and is being cleaned. The label is yellow only for a few moments before a series of black stripes appear over it, indicating that the bed has already been assigned to someone who will occupy it as soon as it is cleaned.

It is only 8:30 am and University Hospital has yet to receive its daily influx of Emergency Department patients. A look at the bed status screen makes it clear that there is a dramatic shortfall in the available bed space – 58 beds are needed, but there are only 38 discharges planned for the day.

Due to the lack of space, 22 patients are resting in non-traditional space, which can include an over capacity patient room, a hallway, conference room, or a recovery space such as the Post-Anesthesia Care Unit (PACU). The Decant Unit, which is only intended to be open 12 hours a day to help relieve pressure for space, has been full and unable to close for two weeks straight.

As she works towards compiling her report on bed needs, Jewell is inundated by several phone calls. The Orthopaedics department has a concern regarding a senior patient who is ready for

discharge to a nursing home. The home has agreed to receive her if she arrives between 10 am and 11 am, but transportation is only available at 1:30 pm, meaning the patient would need to remain in hospital for another day even though she is well enough to leave. Jewell makes a call to see if there is anything that the transportation company can do to shuffle their schedule and pick up the patient on time. She receives a promise that the company will try their best.

She then rushes to the daily team huddle where she’ll disseminate information on bed resources to representatives from each clinical unit, as they create a plan for how they will optimize their space and staffing resources that day. A representative from the Community Care Access Centre (CCAC) is also in attendance, in case they are able to facilitate to help patients return home safely.

Discharge planning is top of mind, as the team discusses their challenges and several units

agree to closely examine their patient population to see who is medically ready to go home and who might be able to move to a different area.

While patients don’t necessarily see the behind-the-scenes work, Jewell and her team members are constantly assessing changing situations to find an inpatient bed for the patients with the highest needs. On any given day, the entire morning’s work may have to be done again in the afternoon – depending on how the need for beds changes. Trying to predict discharges – and thus, available beds – is like tracking shifting sands.

“I’m challenged by the overall workload, the higher acuity patient population that we’re seeing and the difficulty in predicting the discharge process,” Jewell says before pointing out that for the most part, as long as patients are made aware of the challenges the hospital faces, they are understanding. “As long as someone explains to them that, for instance, even though they have private room coverage, they need to be placed in a semi-private room because that is the only space we have available at their time of need, most people are ok with it.”

So what keeps Jewell going?“At the end of the day, it’s all about ensuring

patients get the care they need.”

A day in the life of Hospital Bed Management Coordinator, Pat Jewell

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It has also been identified that patients with heart failure, often called congestive heart failure (CHF), frequently return to the hospital as their condition is complex. To better serve our patients, LHSC began a quality improvement project in mid-2012. Over the course of the past year, a team developed a new toolkit for the care of these patients. The kit includes a range of tools and educational materials that will guide care of the patient from admission through to discharge and self-care at home.

What happens when a patient no longer needs acute-care at LHSC, but they’re not well enough to go home?

Although most patients will go home when they are medically ready for discharge, some require ongoing care. This can include patients who may need home-care, palliative-care facilities, long-term-care homes, rehabilitation or complex continuing care facilities. For most patients, leaving an acute-care environment will provide them with the benefit of regaining a sense of normal life.

In the instances where these patients are not from London, every effort is made to move patients closer to their home hospitals.

“When a patient no longer requires acute-care and they don’t need to complete their recovery period at LHSC, we work with community partners to ensure patients receive care closer to home,” says Judy Kojlak, Director of Access and Flow. “The number of patients that we have been able to repatriate to their community is increasing.”

When repatriation to the home hospital is not an appropriate solution, patients may also be moved to other facilities in the community. For example, many patients requiring rehabilitation may be moved to St. Joseph’s Health Care London’s Parkwood Hospital.

In addition, the South West Community Care Access Centre (CCAC) – a community partner – provides in-home nursing and personal support.

A CCAC case manager is considered an essential part of the health-care team at LHSC. He or she works closely with hospital staff and physicians to identify and assist patients who would benefit from at-home care, or who require assistance connecting with an alternate or long-term-care facility.

Even with the processes in place, beds can still be hard to come by. How is LHSC working towards improving?

Discharge planning is constantly being reviewed to ensure patients are getting the care they need. There is constant focus on improving communication between staff and patients as well as optimizing space and resources.

LHSC’s Predictive Discharge Planning Committee recently examined hospital practices as part of ongoing efforts to provide better patient flow – and improve the patient experience.

Ensuring patients flow through the hospital in a timely manner is a complex problem that must be solved on the ground level – with health-care providers and patients working together as a team.

In addition to the previously mentioned strategies for communicating progress with patients, the health-care team is being held accountable for the role they play. Discharge outcomes are analyzed and used to inform training on predictive care expectations so the hospital can continually reinforce the practices that are working.

“It’s all about discharging patients safely into the best place for those individuals, while at the same time addressing that we’re over capacity.”

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LHSC porters are happy to assist discharged patients to meet up with their ride.

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London Health Sciences Foundation donors are driving surgical innovation at LHSC Did you know LHSC was the first hospital in Canada to use surgical robotics (2003) and now offers the greatest breadth of robotic surgery in Canada? Did you also know that none of it could have happened without generous donor support through London Health Sciences Foundation (LHSF)?

Leading-edge surgical care cannot happen without state-of-the-art equipment. LHSF donors have played a critical role in creating better outcomes for patients by providing the funding that enables the acquisition of the latest technology.

In order for LHSC to continue to offer minimally invasive robotic surgery, LHSF will be fundraising for the next-generation of da Vinci Si HD surgical systems and is excited to provide the opportunity for our donors be part of this extraordinary occasion.

London Health Sciences Centre designated as Canada’s national training centre for robotic surgery

In 2013, LHSC was selected by Intuitive Surgical Inc. – manufacturer of the world’s most sophisticated and widely used surgical robot, the da Vinci Surgical System – as the exclusive training centre for robotic surgery in Canada. The training centre is an integral component of LHSC’s innovative Canadian Surgical Technologies and Advanced Robotics (CSTAR) program, known for both its pioneering work in research and development of robotic surgical technologies and its expertise in delivering high-quality simulation training for surgeons and other allied health-care providers.

CSTAR is the only Canadian training centre (and one of eight internationally) for the da Vinci Surgical System, to certify surgeons in the skills and knowledge they need to perform minimally invasive surgery. Through LHSC, CSTAR physicians have produced a number of world and Canadian firsts in computer-assisted, minimally invasive surgery and have been national leaders in the introduction of robotic surgery to the Canadian health-care system.

Rod Sinn’s voice is rich with undertones. He speaks

with a slight accent that’s hard to place, his cadence

is even and mature, and even if you can’t see him,

you know that he is speaking with a smile. But cutting

through the subtleties, one thing is blatantly obvious:

Sinn is grateful to even have a voice at all.

Like many of his peers in their early fifties, Sinn is a career-oriented family man who enjoys sports and outdoor life. Unfortunately, also like a growing number of his peers, he was shocked to discover that his life hung in the balance due to a diagnosis of oropharyngeal cancer in 2011.

Oropharyngeal cancer, which impacts part of the throat, including the tonsils and the base of the tongue, is a rapidly increasing form of cancer in Ontario, where the number of cases has been doubling every decade.

Sinn’s symptoms seemed innocent at first. “I could see an inflamed tonsil,” says Sinn, who received several rounds of

antibiotics from his family doctor for suspected tonsillitis, but the medications failed to bring him relief. “It was getting really nasty and was really bothering me. I thought, there has to be something more to it.”

When the nagging pain spread into his ear, Sinn sought a second opinion and received a surprising diagnosis – stage 2 cancer of the tonsils. However, due to additional inflammation that included lymph nodes, he would be treated as having stage 4 cancer.

Upon receiving the news, Sinn says his thoughts went on auto-pilot. “The mind goes into a mode of ‘Ok, how do we beat this?’ There was never an option of not beating it.”

Sinn was advised that standard treatment would include chemotherapy and radiation – and while the prognosis was hopeful – there were several risks. Possible side effects included damage to the voice box, loss of taste buds, malfunction of salivary glands and permanent damage to soft tissue and nerves.

“It wasn’t the quality of life that I was looking for when I was 50 years old,” says Sinn.

In his search to find another option, he came across an article mentioning a pioneering robotically assisted throat surgery that was performed for the first time in Canada just weeks prior, by LHSC’s head and neck surgeons, Dr. Anthony Nichols and Dr. Kevin Fung.

After visiting with Dr. Fung and Dr. Nichols, Sinn felt a confidence in the physicians. “It was clear to see that they do this not as a job but as a passion – both of them. It was a feeling that this was the right place.”

According to Dr. Fung, using minimally invasive surgery to remove oropharyngeal cancer offers the potential to avoid side effects of chemotherapy and radiation that impact quality of life. “The vast majority of radiation patients have issues swallowing because radiation causes damage to the throat,” he says, adding that some patients may also need a stomach tube.

In April 2011, Sinn began treatment at LHSC with Dr. Fung and Dr. Nichols, undergoing two surgeries: one to remove the tumour, followed by a second to remove several surrounding lymph nodes as a precaution and to ensure that the cancer hadn’t spread.

To perform the surgery, Dr. Fung and Dr. Nichols used the da Vinci surgical robot, which allows surgeons to reduce the complexity of surgery by providing a better view of the patient’s throat. The minimally invasive surgery is performed by navigating the robot through the patient’s mouth to reach the cancer, which spares the patient from excess scarring on the throat and neck.

“With robotically assisted surgery, we can work from the inside out, rather than the outside in,” explains Dr. Fung.

In Sinn’s case, the surgery also eliminated the need to undergo chemotherapy and radiation.

A few weeks after his last surgery, Sinn received the call that he was cancer free – and other than slight scarring, Sinn’s quality of life remained intact.

“I am blessed to enjoy the wonderful life I have today because Dr. Fung, Dr. Nichols and their medical team chose to offer such exceptional care to me. I am in great health and have an excellent quality of life. They accomplished what my family and I consider to have been a miracle.”

In the fall of 2013, Sinn became a public advocate for supporting LHSC, volunteering to be one of the faces of the Dream Lottery. But as for Sinn’s dream of the future?

“It’s funny,” he says, “because you look at your life and you realize that you’re actually living your dream. Being here with your wife and your children, surrounded by your friends – that is the dream.”

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Go to inside.lhsc.on.ca to learn what inspires LHSC’s Dr. Fung and

Dr. Nichols to continue their pioneering work.

The changing face of cancer treatment “Words cannot express how I feel towards Kevin and Anthony or how grateful I am to have benefited from leading-edge robotic surgery at LHSC,”says Sinn.

Rod Sinn (left) sits with LHSC’s Dr. Kevin Fung, Head and Neck Surgeon, who, along with LHSC’s Dr. Anthony Nichols (pictured on page 12) performed minimally invasive surgery on Sinn to remove his cancer.

Dr. Anthony Nichols, Head and Neck Surgeon (above), along with Dr. Fung (opposite), performed the first robotically assisted and minimally invasive laryngectomy – or the removal of a small portion of the voicebox – at LHSC in 2010.

From left, Lisa Wolfs, Injury Prevention Specialist, LHSC, Kathryn Field, Meg Field, Nigel Field, Kayla Jefferson, Jane Harrington, Injury Prevention Specialist, LHSC, Tanya Charyk Stewart, Injury Epidemiologist, at the LHSC premier of “Distracted Driving – Josh’s Story”.

For more than 20 years, the Impact program – offered through LHSC’s Trauma Program – has aimed to heighten teen awareness of the potential consequences of high-risk behaviours. This past December, the program, which is supported by donors to Children’s Health Foundation (CHF), expanded to incorporate driving issues teenagers face such as distraction and fatigue, and behavioural issues such as binge drinking and peer pressure. In partnership with the Josh Field Network and CHF, the team created a video to be shown during Impact presentations that would provide a personal and relevant experience. The video – “Distracted Driving – Josh’s Story” – focuses on the impact that one moment of distraction still has on Josh’s family, his friends and community, four years after Josh was tragically killed in a motor vehicle collision.

Patient receives heart transplant following at-home wait thanks to new device

After suffering a heart attack, Kitchener native and mother-of-two Suzana De Sousa was diagnosed with congestive heart failure by LHSC’s Dr. Peter Pflugfelder, Cardiologist. Normally, this diagnosis would have meant remaining in hospital hooked up to intravenous pumps while awaiting a heart transplant.

Instead, De Sousa became the second patient at LHSC to receive the HeartMate II Left Ventricular Assist Device (LVAD) developed by Thoratec Corporation. This internally implantable device provided circulatory support and allowed her to leave hospital while continuing to wait for a donor heart.

Dr. Bob Kiaii, Cardiac Surgeon, and the cardiac team at LHSC successfully performed De Sousa’s heart transplant at LHSC’s University Hospital on October 23, 2013. “Her pre-operative condition was optimized,” he says. “She will only get stronger as she continues her rehabilitation and recovery following the transplant.”

From left: Dr. Dave Nagpal, Cardiac Surgeon; Suzana De Sousa, patient; and Dr. Bob Kiaii, Cardiac Surgeon, celebrate De Sousa’s heart transplant.

Canadian first robotic single-site gallbladder removal promises evolution in surgical options for patients

A da Vinci single-site cholecystectomy, or gallbladder removal, was performed for the first time in Canada at LHSC by Dr. Christopher Schlachta, Medical Director, Canadian Surgical Technologies and Advanced Robotics (CSTAR). Patient Melanie Sabino’s gallbladder was removed through a single small incision, hidden in the belly button, resulting in a return to her everyday life in just two days, with virtually scarless results. “This technology represents an exciting evolution in robotic surgery. In 25 years, we have gone from big incisions, to a series of small incisions for each of the surgeon’s hands, to this development of just one small, hidden incision. This is a whole new world that we plan to apply to even more complex surgeries,” says Dr. Schlachta.

Dr. Christopher Schlachta (left) stands with patient Melanie Sabino (right) beside the da Vinci surgical system that was used to perform her gallbladder removal.

LHSC hosts SoHo Community Open House LHSC was pleased to welcome neighbours of the SoHo community (south of Horton)

to an open house where they learned more about the demolition plans for the old South Street Hospital (SSH) and adjacent buildings.

Common questions included how the buildings would actually be taken down, what the timelines for demolition are, and what the City of London has planned for the future of the lands.

Visit the South Street Hospital Decommissioning web page at www.lhsc.on.ca/About_Us/community/southstreetdemo.htm where updated information is posted about the demolition, including a contact line the community can call with questions, comments and concerns.

Residents of the SoHo neighbourhood (south of Horton) in London visited LHSC’s open house for the demolition/decommissioning of the former South Street Hospital building. Photo credit: London Community News

ON THE SCENE AT LHSC

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Thanks to your support, personalized medicine is becoming a reality Personalized medicine – physicians treating patients based on their DNA – is becoming a reality. This innovative area of medicine recognizes that genetic variations make people vulnerable to certain diseases and that the most effective drug treatments should work with, not against, their unique genetic code. The Personalized Medicine Program at London Health Sciences Centre (LHSC) – led by world-renowned clinical pharmacologist Dr. Richard Kim – endeavours to understand the genetic differences between individual patients and, in doing so, provide more effective treatments with fewer side effects. This real-world, patient-centred personalized medicine research will leverage the unique knowledge of LHSC’s personalized medicine experts to lead to better patient care outcomes and reduced overall health-care expenditures. With the support of donors to London Health Sciences Foundation and Children’s Health Foundation, this can happen not only at LHSC but throughout Canada as the Personalized Medicine Program shares its research and leads the way towards patients receiving the right dose of the right drug at the right time.

Decoding the elements for a cure

It’s something that Canadians are all too familiar with – the dramatic effects of winter. The nights are longer, the days are shorter, the cold can be harsh and the weather can deter us from going outside. Considering that sunshine is essential to producing vitamin D in the body, it’s not uncommon to have a deficiency of this important vitamin if you live in a northern region, where skies are normally grey from October to March.

New research led by LHSC and Lawson Health Research Institute’s Dr. Kim, has found that this seasonal drop in vitamin D affects the body’s ability to metabolize an important drug called tamoxifen, which is used to treat and prevent the reoccurrence of estrogen receptor positive (ER+) breast cancer.

“During the winter months we noted that the blood level of the active form of tamoxifen, called endoxifen, is nearly 30 per cent lower than the level seen during summer, and therefore a significant number of our patients may not benefit as much from the drug during winter,” says Dr. Kim.

Dr. Kim is a leader in personalized medicine – which is a new way of practicing medicine using a patient’s genetic blueprint, as well as diet and environmental factors to tailor drugs and dosages specifically to the individual. At his personalized medicine clinic at LHSC, Dr. Kim and his team can identify women for whom tamoxifen will be effective by carrying out genotyping (form of DNA testing) to

learn whether a woman is a poor, low, normal, or rapid metabolizer of the drug. Tamoxifen and endoxifen blood levels are measured using a state-of-the-art piece of equipment called a mass spectrometer.

According to Dr. Kim, it’s antiquated to think a drug affects each person the same way.

“Imagine that you are diagnosed with a major ailment, such as breast cancer,” explains Dr. Kim. “Your doctor prescribes medication to treat it. The hope is that this drug will help you. However, for some of our patients,

and depending on the drug, those drugs or the prescribed dosages may not work well, or could cause unexpected side effects. The percentage of patients that experience this can be significant. When drugs are prescribed to fit an individual’s genetic profile, he or she can get timely access to better, safer treatments and avoid needlessly taking medications that are less likely to work, or cause significant side effects.”

In addition to the seasonal effect, Dr.Kim found there are other factors that affect tamoxifen’s efficiency.

Research shows that, due to their genetic makeup, nearly 10% of Canadian women are less likely to benefit from

tamoxifen’s cancer fighting benefits because their livers do not produce enough of a certain enzyme that converts the drug into its active form. If these women unknowingly take the standard dose of tamoxifen for five years, the treatment may be suboptimal and possibly put them at a greater risk of their cancer coming back.

Also, there are many drug interactions, such as those caused by common antidepressants, which can markedly

reduce the liver’s ability to generate the active form of the drug.

Armed with the knowledge and information gathered from the research, Dr. Kim and his team can help advise physicians in caring for their patients. “These new clinical and genetic markers can help identify patients who will benefit from tamoxifen, as well as those patients at risk of suboptimal results. Now we can identify a woman who, in the past, would have been prescribed an ineffective treatment and look for other options, and if the test shows a woman is a normal metabolizer, it gives reassurance that she’ll really benefit from therapy.”

For those who metabolize the drug poorly, doctors may recommend switching to another type of hormonal therapy or to increase the tamoxifen dose in consultation with the patient’s oncologist, and see if the endoxifen levels reach the therapeutic range. Also, patients are now encouraged to consider vitamin D supplementation, especially over the winter months.

The discovery of the many factors affecting the efficacy of tamoxifen marks just one of many rays of hope for the future of personalized medicine.

RESEARCH

Medical professionals have long known that the level of vitamin D in our body drops in the wintertime, especially if we live in a northern region. However, new research led by Lawson Health Research Institute’s Dr. Richard Kim has found that vitamin D deficiency can affect the body’s ability to metabolize an important drug used in breast cancer treatment.

Go to inside.lhsc.on.ca to hear Dr. Kim explain

why the future of personalized medicine

is bright.

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At his personalized medicine clinic at LHSC, Dr. Kim uses patient-specific genotyping tests to treat patients.

Making an Impact on high-risk teen behaviours

“Distracted Driving – Josh’s Story” can be viewed at inside.lhsc.on.ca.

When drugs are prescribed to fit an individual’s genetic profile, he or she can get timely access to better, safer treatments

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Do:• Get into a regular and relaxing routine before bed. This will prepare and condition your body to sleep.

• Get up each day at a consistent time. Sleeping in and napping can have a negative impact on your sleep schedule.

• Make your bedroom as relaxing as possible – ensure your bed is comfortable, limit exposure to light and ensure the temperature is not too hot or too cold.

• Get physical: Exercising vigorously early in the day or late in the afternoon can help promote a relaxing sleep. Gentle exercise like yoga, can be done before bed to help relax the body.

• Get exposure to natural light during the daytime to help maintain a healthy sleep- wake cycle.

• Get out of bed if you are having a hard time falling asleep. If you are kept awake by worrying thoughts, take time to write them down and commit to addressing them the next day. Engage in an activity that limits mental activity (e.g. a word search), in a dimly lit room to help your brain wind down.

What are some tips for a good night’s sleep?A good night’s sleep helps protect our overall health and recharges us so we can better manage the stress of everyday life.

However, for many people, restful sleep can be a challenge. At some point in life, approximately 40 per cent of the population experiences issues with getting to sleep, staying asleep or feeling well-rested.

To help set yourself up for a successful slumber, LHSC’s Sleep and Apnea Assessment Unit suggests the following tips:

Don’t:• Consume or use stimulants,

such as caffeine, which can have effects that last up to 48 hours. To get a better

sleep, avoid caffeine and nicotine close to bedtime.

• Have a nightcap. While alcohol can speed the onset of sleep, it also disrupts sleep as your body attempts to metabolize the alcohol.

• Nap during the day as it candisturb sleep patterns.

• Eat right before you sleep,especially large meals and spicy

food. Chocolate, which contains caffeine, should also be avoided.

• Use your bed for mentally stimulatingactivities like watching TV, listening to music

or reading.

• Use screens (e.g. TV, computer, tablets, phones, etc.) near bedtime. These devices emit a blue wavelength of light, which can disturb your

body’s sleep-wake cycle.