Each year, the Research Institute of St. Joe’s – Hamilton publishes an annual report to highlight how research at our hospital impacts the science of medicine and the lives of patients around the world.
This year’s report explores regional and international collaborations, state-of-the-art treatments, new ways of thinking about cardiovascular disease, the vision of the urological oncology research centre, and even the science of research design. Download your copy today to learn about the exciting advancements made throughout 2018.
Need a knee replacement? St. Joseph’s Healthcare has a robot that does that
St. Joe’s will do research to prove the technology works to avoid pitfalls plaguing robotic prostate cancer surgery.
Feb 25, 2019, by Joanna Frketich The Hamilton Spectator
Canada’s first knee replacements by a doctor-controlled robot have taken place at St. Joseph’s Healthcare as part of a study to prove the effectiveness of the technology and avoid the ongoing funding pitfalls plaguing prostate cancer surgery.
The robot has been used in four knee operations since Jan 18 in a pilot study funded by hospital donors.
“It’s very fledgling,” said Dr. Anthony Adili, who did the surgeries. “We’re just starting down a very exciting path … At the end of the day I think patients will benefit immensely from this new technology.”
St. Joseph’s, which specializes in robotic surgery, is getting the proof it needs from the start to show the technology is worth the extra cost so it doesn’t end up embroiled in the same dispute it faces with prostate cancer surgery.
“We’re in a golden opportunity to do that kind of pivotal research to inform our decision-making,” said Adili, chief of surgery at St. Joseph’s. “The research is being done (elsewhere) but it’s not high quality research so it’s hard to make definitive decisions and definitely difficult to make policy decisions. We want to produce that high quality data.”
The research is significant because a lack of evidence was behind a controversial recommendation in 2017 by the Ontario Health Technology Advisory Committee (OHTAC) against publicly funding robotic surgery to remove a cancer patient’s prostate gland.
It was a stunning blow to St. Joseph’s, where the vast majority of radical prostatectomies are done with the help of the da Vinci robot system.
Currently, the province pays the hospital the same price as the traditional operation and donors make up the extra cost of the robot. It’s an increasing burden on the St. Joseph’s Healthcare Foundation as the robot is rapidly becoming the surgery of choice with men from Kitchener to Niagara willing to travel and wait longer to get it.
A final decision on whether the province will eventually fund the robot for prostatectomies at an estimated cost of $800,000 — $3.4 million a year has been put off while St. Joseph’s gathers evidence on how it saves the health care system in other ways, such as a faster recovery time, since it’s no longer possible to do randomized trials.
“It’s so ubiquitous and it’s almost the standard of care,” said Adili. “It’s impossible to randomize someone to robotic prostatectomy versus an open prostatectomy. Nobody will go for it. We lost that opportunity.”
Orthopedic robotic surgery was approved in Canada and the United States only in the last year so high-quality studies can still be done. It’s the same for robotic thoracic cancer surgery with St. Joseph’s already running a multicentre trial.
“We don’t know who it’s going to benefit so we can do these randomized trials and develop that data that will help drive decision-making,” said Adili.
The biggest roadblock is that St. Joseph’s is the only centre in Canada doing robotic orthopedic surgery, making a multi-site trial of thousands of patients impossible to do here. With a price tag of $2 million a robot, it will be hard to find other centres with the appetite to join in.
“We’re going to have to partner with centres in the United States and convince them to contribute data,” said Adili. “The problem is they are buying robots like crazy because it is driving their business. They are going to be less inclined to want to randomize one versus the other. Some of our progress will be hampered until we get more units in Canada because Canadians have a very different mindset and will participate in trials.”
In the meantime, St. Joseph’s has started the pilot study that it hopes will provide enough evidence to get grants for the eventual large trial.
It’s important because Adili says one in five patients are currently unhappy with the outcome of their knee replacement and the robot’s precision could drop that number substantially. In addition, it makes partial knee replacements much easier, so surgeons will be more likely to do them.
“By replacing just the bad part of the knee, I’m leaving more of the patient’s normal anatomy behind,” said Adili. “It should feel like a more normal knee, recovery should be quicker and they should have better functionality. A total knee, although it is a successful procedure, it still does not match the mechanics of a normal knee.”
With the popularity of the robot for prostate cancer, Adili doesn’t expect any difficulty in recruiting patients.
The first was 66-year-old Peter Sporta from Oakville, who waited an extra two months to get a robotic partial knee replacement on Jan. 18.
“I wasn’t scared at all” Sporta said about being the first patient. “I couldn’t wait.”
Sporta was in the hospital for one night and walking the next day.
“Within three days I threw away my crunches and my cane,” he said. “For sure I would recommend this.”
Two Hamilton researchers will study post traumatic stress in emergency services
Media Outlet: Hamilton Spectator | Date: February 14, 2019 | Reporter: Joanna Frketich
Hamilton researchers are teaming up with scientists in France to determine the links between mind and body that could one day bring about more personalized mental health treatments.
“The hope for the patients one day is that when they come with depression, we don’t give them only an anti-depressant,” said Dr. Flávio Kapczinski, professor of psychiatry at McMaster University and St. Joseph’s Healthcare.
“We give them a whole strategy on how they would get outside the risk zone for depression.
“We could give them exercise, correct their metabolism with some sort of diet and give them anti-inflammatories.”
The partnership with the Pasteur Institute was one of three new Hamilton mental health projects launched in February.
The other two will investigate post-traumatic stress injuries (PTSI) in public safety personal such as firefighters, paramedics, police officers and correctional workers.
Both received grants of up to $150,000 from the Canadian Institutes of Health Research as part of $2.95 million in federal funding announced Feb. 8 to studies that increase understanding of how to identify, treat and prevent PTSI.
Margaret McKinnon, chair in mental health and trauma at McMaster, will do a randomized control trial to test a new way to treat PTSI in public safety personal with other health conditions.
Occupational therapist Sandra Moll plans to design a mobile health approach to prevention and peer support.
“Public safety personnel put themselves in harm’s way to protect Canadians, putting them disproportionately at risk of post-traumatic stress injuries,” federal minister of public safety and emergency preparedness Ralph Goodale said in a statement.
“Our country must do more to protect the mental well-being of public safety officers on-the-job. The initiatives will help address gaps in PTSI research and inform long-term plans to support the mental health and well-being of our public safety personnel.”
Meanwhile, the new partnership with the French researchers is significant because it gives St. Joseph’s Healthcare and McMaster access to basic science research that they don’t have now.
In turn, they offer Pasteur large cohorts of patients from West 5th hospital that the French are currently missing.
“We are accumulating a lot of data in this field now and thanks to this collaboration we’re going to have access to large cohorts,” head of Pasteur’s perception and memory unit Dr. Pierre-Marie Lledo said during a trip to Hamilton on Feb 7.
“We get a full picture of how the brain functions by having access to the clinical data.”
It’s also unique because French researchers generally team up with Quebec investigators.
“When France would partner with Canada they never crossed the Gatineau River,” said Kapczinski.
“Now the commitment of the French Embassy is to bring to the attention of French scientists this whole perspective of dealing with many other centres like McMaster. We are looking to the idea of strengthening the scientific links between Canada and France.”
So far, funding is primarily from their own institutions and the French Embassy, but they are working on applying for grants to study many different potential mind and body links.
“We were finding our patients when they have depression, they have a lot of inflammation in their blood,” said Kapczinski.
“We didn’t know the cause of that. Pasteur is famous because it’s where immunology and inflammation started to be understood … so we reached out to the director and he was very excited.”
Other questions vary from gut bacteria to exercise to metabolism to electric signalling between fatty tissues of the brain.
“People who suffer from depression they suffer a lot of brain changes like accelerated aging,” said Kapczinski.
“The brain and the body as a whole starts to age faster and we want to understand the mechanisms associated with that.”
The following article was featured in Canadian Healthcare Technology on November 8, 2018. Written by Dianne Daniel.
Community hospitals have also invested in new software, enabling physicians, care partners and patients to access information more easily
Complex cardiac care in Ontario is no longer limited to major urban teaching hospitals. New technologies and management techniques – coupled with strong partnerships – are strengthening advanced regional programs, bringing excellent care closer to cardiac patients where they live and dramatically improving medical outcomes.
Royal Victoria Regional Health Centre (RVH) in Barrie launched its regional cardiac program in partnership with Newmarket’s Southlake Regional Health Centre in January, enabling its cardiac team to perform angiograms and percutaneous coronary intervention (PCI or angioplasty). The program is supported by 10 cardiologists, a dedicated seven-bed coronary care unit, two catheterization labs (cath labs) accompanied by a 16-bed recovery unit, and a 32-bed cardiac/renal unit for general cardiac care.
Planning for advanced care delivery began in 2012 and was based on a strong vision to create a comprehensive, centralized electronic system specifically for cardiac care. “We really felt our solution needed to describe the patient’s cardiac journey and that journey should be available essentially anywhere in the world a physician would need it, if they needed access to that information,” said Selma Mitchell, operations director of the Simcoe Muskoka Regional Heart Program & Regional Renal Program.
To streamline workflow throughout its cardiac care program, RVH partnered with Philips, implementing the IntelliSpace Cardiovascular image and information management solution along with supporting applications for nursing documentation and patient monitoring. Physicians log in to see all patient test results, including echocardiograms, electrocardiograms, cath lab exams and holter monitors, and the system is integrated with RVH’s existing Meditech electronic health record system.
As Mitchell explained, it’s not only the diagnostic report that’s available, but the live image too. “Our patients love it. We pull this up at the bedside, after the patient has had the procedure, and their physician will show them what their angiogram looked like,” she said. “It’s really interesting for them to see their images in real life.”
The advanced system is accessible beyond the walls of RVH. If a patient is transferred to Southlake for a more complex procedure or surgery, for example, the treating physician there is able to access and view all prior diagnostic testing.
“You can’t just deliver a hardware system,” explained Mitchell. “You need to be able to connect it to the patient and the software piece is integral … that was probably the most important aspect for us, having a system where we could connect all of the dots.”
The “dots” are also being connected between RVH and the smaller regional hospitals within its catchment in the Central local health integration network (LHIN). Recently, RVH integrated its electronic cardiac system with the Huntsville District Memorial Hospital site of Muskoka Algonquin Healthcare, enabling physicians there to share images and reports with cardiologists at RVH.
“A few years back, if a patient had to be referred to another physician, we would have had to taxi a CD down to that partner hospital which took time,” said RVH Cardiac IT team member Stef Keown. “Now they can access it in seconds versus hours.”
By 2020, the new regional program will operate 24/7 with paramedics transporting North Simcoe Muskoka heart attack patients directly to RVH for treatment, providing lifesaving intervention within 90 minutes for most patients. In the meantime, the plan calls for a cautious, phased ramp-up of cardiac services, supported by ongoing partnerships with Philips for infrastructure and Southlake for tertiary and quaternary services, including advanced cardiac surgery and heart rhythm interventions.
Janice Allen, director of Southlake’s Regional Cardiac Care Program, said the most important objective of the regional focus is to deliver excellent cardiac care while reducing patient travel. “It truly is one program with two sites,” said Allen, adding that the Southlake cardiac surgery team conducts satellite clinics at RVH as needed for complex patients. “It’s really great from a regional perspective to be able to offer this cutting-edge care closer to home for our patients. Otherwise they would have to be travelling to academic centres,” she said.
In February 2018, Southlake completed a redevelopment of its cardiac labs, providing more efficient care for patients in need of complex cardiac interventions across the region. The third largest cardiac centre in Ontario, it now operates three cath labs outfitted with state-of-the-art imaging systems for diagnostic angiograms, angioplasty and structural heart procedures, and three dedicated electrophysiology suites for heart rhythm diagnostic studies, ablations and implantable devices such as pacemakers and defibrillators. The new equipment – which includes the latest in 3D imaging and mapping – creates opportunities for future growth, said Allen.
Since inception, the centre’s Regional Cardiac Care Program has treated more than 160,000 patients, completing 93,370 diagnostic tests and exams last year alone. In addition to more than 6,000 diagnostic catheterization procedures, 1,000 surgeries, 752 electrophysiology studies and 687 cardiac ablations, the centre performed 71 transcatheter aortic valve implants (TAVIs) in 2017 and is awaiting approval from the Ontario Ministry of Health and Long-Term Care to add mitral valve clipping procedures.
“The other procedure we’re looking at doing is left atrial appendage closure for patients who have Afib (atrial fibrillation), who are at high risk of bleeding on an oral anticoagulation therapy,” said Allen.
Remote monitoring of patients is another part of the regional program which is contributing to fewer hospital readmissions and reduced lengths of stay. Patients who receive pacemakers or implantable cardioverter defibrillators (ICDs) and who provide consent for remote monitoring are able to download information from their devices daily for review by nurses. Monitoring is also provided for congestive heart failure patients, who track their weight, oxygen saturation levels, heart rate and blood pressure.
“If patients are trending in the wrong direction – if their weight is going up or their oxygen saturation is trending down – they may not be symptomatic at that point, but our team can pick up on that and call them,” she said, noting that the same monitoring service is provided to elderly patients who reside in long-term care settings.
An added advantage of the regional program is that Southlake is able to bundle contracts with industry partners and vendors into one “innovative procurement with multiple streams,” Allen said. Innovative procurement means vendors don’t simply sell products, they work with the hospital to improve quality performance indicators such as readmission to hospital, length of stay and mortality rate. “It was a lot of work,” she said. “We’re very proud because we were able to deliver benefits to our patients through a procurement strategy. We haven’t seen that before.”
St. Mary’s Hospital in Kitchener is also aiming to use innovative procurement to support its strategy for a new regional cardiac program. As Chief of Cardiovascular Services Dr. Brian McNamara described, the approach is more about outcomes than widgets.
“Traditionally, hospital procurement has been ‘we use 2,500 stents per year, we promise to buy them from you at this price,’” he said. “This is more about ‘we want to have a lower stent thrombosis rate, or a shorter door to balloon time or a shorter length of stay. How can you help us do that?’”
The hospital will meet with local technology companies and leaders in October to provide them with an outlay of its plan for a Waterloo Wellington Regional Cardiac Program – an expansion strategy that is supported by the Waterloo Wellington LHIN and is currently seeking funding approval by the Ontario Ministry of Health and Long-Term Care. Dr. McNamara said the need for additional services is “irrefutable.”
Over the past 15 years, St. Mary’s Hospital has grown its cardiovascular services to the point where it is now completing more than 6,000 cath lab procedures each year. Nine years ago, the centre performed 900 PCIs per year; this year it completed more than 1,800. Yet the underlying infrastructure hasn’t changed, meaning the two existing cath labs are used around the clock, straining equipment and resources.
“A few years back St. Mary’s leadership and the Board instituted a Lean management strategy to try to extract the most value from the resources we have – both physical and financial – and those efforts have squeezed absolute maximum capacity out of the existing infrastructure,” he said.
Services provided by St. Mary’s include pacemaker and ICD insertions, coronary artery bypass and valve surgeries, catheterizations and PCI procedures, Transcatheter Aortic Valve Implantation (TAVI) and diagnostic coronary angiography. There is a very busy pacemaker and ICD and CRT Program. The Cardiac program is supported by 18 cardiologists, four surgeons, five cardiac anesthetists and a dozen nurse practitioners. According to a 2017 national report on quality outcomes at Canada’s 38 cardiac centres, St. Mary’s is performing better than the national average and is among the top three.
“For a small place, we do PCI and cardiac surgery at a level that’s commensurate with the top three places in the country and some of our metrics are better,” said Dr. McNamara. For example, Canadian average mortality rates following cardiac procedures range from 1.3 to 2.3 per cent whereas St Mary’s rate ranged from 0.5 to 1.6 per cent. The average readmission rate following PCI was 7.4 per cent; St. Mary’s was 5.8 per cent.
In addition to the hospital’s strong cardiac performance, the community is now better served due to changes in outpatient care delivery. The cardiologists are aggregated together into one, large outpatient clinic. Before, family doctors would fax referrals and send consult requests all over the Kitchener-Waterloo region. Now the entire service is staffed out of one clinic and each cardiologist leaves a few openings in the weekly schedule to treat emergency patients.
“It’s much more responsive to the community and it has completely transformed outpatient cardiology access,” said Dr. McNamara.
St. Mary’s Hospital, in Kitchener, Ontario, is performing better than most cardiac centres and is among the top three in Canada.
Moving forward, the expanded plan includes developing a “hub and spoke” model for advanced cardiac care delivery, with St. Mary’s Heart Function Clinic as the main resource for guidance, order sets and care of the highest risk and sickest patients in its catchment area.. The “spokes” will be satellite services provided in smaller communities, but under St. Mary’s guidance, he explained.
St. Mary’s regional cardiac program serves over 20 hospitals in a geographic rectangle stretching from Simcoe to Tobermory, along the coast of Lake Huron to Goderich and east to Guelph. One of the goals of the expanded Waterloo Wellington Regional Cardiac Care program – which includes the addition of an electrophysiology lab to treat advanced heart rhythm disturbances as well as remote cardiac rehab – is to develop a comprehensive digital strategy.
Concurrent with its strategic plan to expand regional cardiac care services, St. Mary’s is in the midst of a large Cerner electronic medical record implementation in conjunction with Grand River Hospital. Dr. McNamara expects the new system will enhance the flow of information between satellite sites so that a physician at one location can get an ECG in front of an on-call cardiologist at St. Mary’s in a secure manner that protects patient privacy.
“It’s one of those Tower of Babel situations. The hospitals we work with all use different platforms for diagnostic imaging, records; it’s difficult to talk to each other,” he explained. “The hope is one EMR will enhance the to and fro of information to our partner hospitals in a more seamless way.”