Research at the front lines of health care

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Scientists and physicians aren't the only ones conducting important, life-changing research at Sunnybrook. Health-care professionals in myriad roles are involved in Sunnybrook's program of practice-based research and innovation (PBRI) - drawing from their daily experiences on the job to conduct research into improving the patient experience.

Sunnybrook's strategy for PBRI is driven by the belief that health professionals at the point-of-care have crucial knowledge and abilities that can play a critical role in quality patient care. Here are some examples of this philosophy in action.

Louise Rose, nurse researcher:
Furthering critical-care work

Louise Rose loves giving a voice to seriously ill patients – literally.

Rose's working mission − to influence decision-making in health-care policy and funding − includes researching the care and management of patients requiring mechanical ventilation.

One of the several collaborative studies she is leading involves the use of a communication device, known as an electrolarynx. "To be able to communicate is a fundamental need we all have," says Rose. "Being unable to communicate is one of the most frustrating things about being a patient in the intensive-care unit."

She's referring to how the speaking ability of critically-ill patients can be hindered when using breathing devices that aim to save their lives. Some may need breathing machines (ventilators) temporarily, while others may need breathing tubes (tracheostomy) permanently. Breathing tubes use a balloon (called a cuff) that, when inflated, helps to prevent saliva and other secretions from entering the lungs, which could lead to infection.

When this medical equipment makes speaking impossible, health-care providers may need to read patient's  lips or facial expressions, "but that's still extremely difficult and often leads to frustration for our patients," says Rose.

Giving patients their voice back is the motivation behind the project Rose is leading to test whether they can be trained to use the electrolarynx.

The device, sometimes known as a throat back, is more commonly used by cancer patients who have had their voice boxes removed. About the size and shape of a small electric shaver, it is placed under the jawbone and produces vibrations to allow speech.

Terry Chaikalis, for instance, has multiple sclerosis and requires a tracheostomy with the cuff inflated. He says that since using the electrolarynx, "I'm enjoying talking again." He hopes to get his own device for his move to long-term care.

Many patients and their loved ones are happy about the electrolarynx – one seriously injured patient was a "changed man" after learning to use it, says Rose, because he could once again communicate with his wife.

Still, it takes some getting used to, because it makes a buzzing noise, says Rose, who would like to collaborate with engineers to design a quieter and easier-to-use device.

Rose thrives on collaboration with professionals who have diverse skills. "Most of health care is a team − it's not a single individual − so you have to include the perspectives of all those key members, both in applying things at the bedside and in doing research," she says.

The U.K.-born Rose, who studied at Massey University in New Zealand and then earned her PhD at University of Melbourne in Australia, was lauded for her "wealth of experience" when she was named to the TD Nursing Professorship in Critical Care Research in 2014.

Now established in the role,  Rose says: "I enjoy being here at Sunnybrook where I am close to the clinical environment. I can go up to the ICU (intensive-care unit) and be involved in data collection and screening, and talking to my research staff rather than just being in an office."

Sabrina Rafaeli is on a mission to make the OR a quieter place for patients.

Photograph by doug nicholson

Sabrina Rafaeli, registered nurse:
'Silent induction' and other ways to reduce patients' anxiety

As a dedicated operating room (OR) nurse for more than a decade, Sabrina Rafaeli has come to realize that patients preparing for surgery respond best to the sound of silence.

The 32-year-old is a team leader on night shifts in the OR, which can be extremely busy with trauma patients. On her day shifts, much of her OR work involves patients undergoing ophthalmological and gynecological elective procedures. She does everything from verifying surgical counts to working to ensure patient safety, all while collaborating with anesthetists, surgeons and others.

Rafaeli says patients can become unsettled if exposed to noises in the OR right before their surgeries. These disquieting noises can be as simple as the clanging of surgical instruments or the idle chatter of the surgical team.

Rafaeli, who joined Sunnybrook in 2011 after moving to Toronto from Israel, says one particular event gave her the idea for her research work.

"A few months ago, I was circulating in the operating room when it struck me how noisy it can get. Everything from staff talking, the radio playing, monitors beeping, metallic instruments clanging and people coming and going," says Rafaeli.

"As an operating room nurse, I notice extreme anxiety in patients. Sometimes patients don't verbalize it, but you see their heart rate and blood pressure go up. They may ask to go to the washroom. They don't have to tell you they're scared, but we know those patients are anxious, and we are there to help them and make them feel better," she adds.

As part of her research, Rafaeli created surveys for patients to evaluate their anxiety levels before and after each surgery, and to help her determine how certain interventions could decrease those feelings.

"If we have patients who are anxious before surgery, they will wake up anxious and post-operative anxiety affects post-operative pain, which means the patient may require more pain medication for recovery," she says. "And if they need more narcotics in recovery, that recovery may take longer."

To that end, Rafaeli has devised some novel approaches to managing noise levels, including a "silent induction" plan: During the administering of the anesthetics, there should be no counting of instruments or discussions among staff, who would also be asked to avoid entering the room unnecessarily and to turn off their pagers. She also aims to increase surgical teams' awareness of the impact of noise on patients by holding educational sessions, hanging posters around the OR and engaging "noise champions" to oversee silent inductions in their practice.

Jenn Bowler, social worker:
Improving the discharge experience for trauma patients and families

Jenn Bowler's years of social work experience at Sunnybrook's Tory Regional Trauma Centre have taught her that patients and their families need help from the moment a life-altering injury happens, through to when they are discharged and long after.

"Traumatic injury and hospitalization are always overwhelming and intimidating events," she says. "Besides physical injuries, there are typically significant psychological and social impacts and stressors on the patient and family."

Bowler has a master's in social work from Wilfrid Laurier University and joined Sunnybrook in 2007. Working in what is Canada's largest regional trauma centre, she is among three social workers who get involved within the first day or two of a patient's admission. She says: "We have a continuity-of-care model where we follow patients from admission to point of discharge from hospital."

Her work, she says, provides her the opportunity to work with trauma patients who have sustained injuries that involve many systems in the body, including the brain and spinal cord, from serious accidents or sometimes violence. She offers in-depth support and counselling to patients and their families to help them adjust during times of crisis or while they are dealing with grief. This can involve aiding their transition out of the acute-care environment into their homes or into the community, including during rehabilitation.

It is Bowler's hope that her work – focusing on improving the educational materials given to patients and families after discharge – will help patients better deal with that transition from hospital to home, and be more prepared to cope with their injuries.

Bowler's discharge packages educate trauma patients about problems to watch for, precautions to take and provides helpful tips and resources. That may mean, for instance, providing information to help a patient with a concussion and a broken leg learn how to shower with a cast, apply for Employment Insurance while off work and deal with headaches and fatigue. As trauma patients and their families have complex injuries and needs, it is essential that they are empowered and educated to improve their confidence and better deal with their physical and emotional recovery at home.

Bowler is driven by the people she helps. "Patients and families amaze me with their strength and resilience," she says.

Jonathan Russell, ICU nurse:
Working to improve staff handovers in critical care

Communication is key in most jobs, but for a medical professional, knowing everything that happened during a previous shift is vital.

To that end, Jonathan Russell's research involves introducing and evaluating a tool to help organize and detail the information that is transferred between nurses as shifts change in Sunnybrook's Critical Care Unit – known as the "handover" process.

At its core, a better handover means better quality care. "The idea is to change the way we think about handover by providing a framework around which to organize it. Structured tools make handovers more accurate by being specific about what information needs to be shared. For our patients, it means they can be confident that the person coming on shift has all the information needed to take care of them," says Russell.

He earned his masters of science in nursing in 2009 from McGill University and relocated to Toronto in 2010 to work in critical care at Sunnybrook. Russell, 33, is also currently a student in the nurse practitioner program at the University of Toronto.

As a charge nurse, he says that effective handovers are necessary to improve the quality of care provided to patients and their families, particularly in intensive-care units (ICU). While handovers occur throughout the hospital − for reasons such as new admissions, change of shift or unit transfers – those that take place in the ICU differ in that the information tends to be of high volume and complexity. "The trick is finding a way to provide a comprehensive handover while avoiding information overload," he says.

Russell figures that improving the transfer of information process will mean safer transitions in care between providers, and better patient care.

Amy Wainwright was on the team that created Sunnybrook’s myHip&Knee app.

Photograph by doug nicholson

Amy Wainwright, physical therapist:
New approach to improving patient experience of post-op pain

Amy Wainwright traces her passion for helping others overcome knee and hip problems back to her childhood.

"I had a lot of pain as a child; I had trouble with my knees and would go to physiotherapy every other Friday" at a children's hospital, she recalls.

Wainwright, 34, has an undergraduate degree in kinesiology from McMaster University and a masters in physical therapy from the University of Toronto. She has been a physiotherapist at Sunnybrook's Holland Orthopaedic & Arthritic Centre for eight years.

Patients with hip and knee replacements often experience challenges with pain management and rehabilitation, she explains. But there are unique concerns for patients who undergo knee replacement. They often experience more pain, and they have the added pressure of having to work to regain their knee movement quickly, beginning the day after surgery.

Wainwright has been involved in several patient-centred initiatives, including working on the development of a mobile app for patient use. Sunnybrook's myHip&Knee app helps patients prepare for hip or knee replacement surgery by sending them reminders about what they should be doing before an operation, for instance.

After surgery, the app can help them keep on track during recovery by sending them daily questions to answer about their health. It also has a range-of-motion tracker that allows a patient who has had knee replacement to gauge how well the knee is bending and straightening.

Wainwright also plays an important role in the innovative, post-op knee replacement classes for patients, which offer peer support and focus on mobility, strengthening and functional training.

Wainwright says patients in the classes have reported that the classes are motivating and have helped them build confidence and make "functional gains."

She is also part of an inter-professional committee that uses patients' feedback to find ways to help them with pain management.

As patients identify a need for more information on how to better manage their pain after discharge, one aspect of Wainwright's fellowship program research is focused on creating new educational resources.

"Our patients have played such an important role on the team by identifying the issue and then helping us by providing important insights into how to make the resources the most meaningful to them," she says.

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