Objectives:
Kidney failure is a major health problem, affecting >41,000 Canadians, a 65% rise since 2000. Kidney transplantation improves both patient quality of life and survival. Unfortunately, only 40% of kidney failure patients receive transplants due to an organ shortage. Donor organs from donation after cardiac death (DCD) deceased donors (~20% of all donors) represent the fastest growing source of organs worldwide. Unfortunately, these DCD kidneys are more prone to injury which leads to higher rates of delayed graft function (DGF), poorer long-term function and reduced patient survival compared to living donor transplanted kidneys. We proposed a novel, feasible and inexpensive solution to improve outcomes in DCD transplantation. Our previous work showed in animal (rat and pig) models of kidney transplantation that the supplementation of organ preservation solutions with experimental hydrogen sulphide (H2S) donor molecules leads to an impressive improvement in kidney function and survival. Unfortunately, H2S donor molecules, as described above, are decades away from clinical use. We therefore proposed to translate our experimental findings to clinical practice by evaluating STS as a clinically viable H2S donor molecule with the aim of firstly elucidating the role of STS in organ preservation in animal and ex vivo models of transplantation and secondly to culminate in the world’s first clinical trial using STS as an H2S donor molecule in human kidney preservation and transplantation.

Innovation:
Our institution has been a strong proponent of innovation and a pioneer in organ transplantation internationally. Through this grant, we introduced several new innovations to our site including novel, reproducible protocols, and platforms useful for the ex vivo testing of organs prior to transplantation. These platforms will enable future work whereby marginal human kidney grafts are “tested” and potentially “repaired” prior to being transplanted into patients. In addition, we carried our pilot
studies in a “first-in-human” trial of a novel organ preservation solution in the clinical setting.

Potential for Spread:
There is interest from other transplant centers across Canada (UBC, UofA, Winnipeg, McMaster, Ottawa, and Queen’s) for a multi-center randomized controlled trial based upon our preliminary findings. In addition, other organ groups (liver and lung) have shown interest to evaluate this new technology in impacting graft outcomes. Given that STS can be easily added to the existing preservation solutions without the need for additional personnel, its implementation to any
transplant protocol in the world would be simple. Given the rise in DCD transplantation, this therapy is likely to have a major influence on the care of transplant patients worldwide.

Beyond the Innovation Fund:
We received a CIHR Operating Grant for the continuation of this project. A new application has since been submitted to Health Canada to expand the patient cohort to include all kidney transplant recipients. This is the first step to securing a multi-center trial and we are very excited to lead this initiative.

Objectives:
Our ability to maintain safe antenatal care during COVID, with transition to video-based care and reduced ultrasound resources required innovative thinking: otherwise serious adverse maternal (inadequate diagnosis of preeclampsia) and fetal (stillbirth from undiagnosed fetal growth restriction) placenta-mediated complications likely would have risen. Pre-pandemic no systematic screening for placental dysfunction was in place. Consequently 1950’s-style care (frequent in-person clinical assessments) prevailed, with targeted ultrasounds. The potential impact of the study intervention was to at least preserve, if not improve, clinical outcomes for major placental complications. Our opt-out screening study provided “safety-net” care; we planned to screen 5,000 subjects, and ultimately nearly doubled this sample size for test evaluation.

Innovation:
In March 2017 Mount Sinai Hospital/UHN became the first N. American Hospital to launch real-time PlGF testing for suspected placental complications, following a 2016 UK national institute for clinical excellence (NICE) recommendation; by early 2021 we published our initial experience in Hypertension, an achievement that led to endorsement by the Ontario MOH in 2023. This project innovation was to provide PlGF as a screening test aligned with the 24-28 week blood test for gestational diabetes mellitus (GDM), and embed result into clinical care. Using a 100pg/ml cut-off at the 2.5th centile, a small screen-positive group received maternal-fetal monitoring, while the majority were reassured that virtual care could continue up to 36 weeks, thereby eliminating 3 in-person visits and 1-2 ultrasound examinations for each. Ultimately 9,037 pregnancies were screened over a 3-year period with a primary outcome of preterm birth <34+0 weeks. No participant died, while 36 (0.4%, 1/250) experienced stillbirth; no stillbirths were considered preventable. Low PlGF (<100pg/ml) had an adjusted relative risk of 92 (95% CI 65-31) for the primary outcome. 2/3rd births <34+0 weeks (n=105) were medically indicated and for this subgroup PlGF <100pg/ml achieved an area under the curve (AUC) of 0.90 (0.85-0.94). Over 50% of patients with a PlGF <100pg/ml delivered within 50 days of screening. Therefore, this fully powered project showed that 24-28 week PlGF aligned with GDM screening, achieves high test precision for major placental complications causing early preterm birth <34+0 weeks gestation.

Potential for spread:
A manuscript is under consideration at British Medical Journal. A PlGF-focused Provincial webinar on PlGF on 29th May 2024 attracted 154 participants. An abstract has been accepted at the Society for Maternal-Fetal Medicine, Rome September 2024). Thus far we have helped 3 institutions (Ottawa, Regina, Vancouver) launch PlGF testing, and (May 29th, 2024) CIHR notified us that our PGF knowledge translation grant to bring 20 Canadian stakeholders to Toronto for a Fall 2024 implementation meeting was successful.

Beyond the IF:
A CIHR project grant application (March 2024) is pending. Next we plan a Fall 2024 CIHR multisite preeclampsia prevention trial submission whereby at enrolment participants take evidence-based aspirin from 12 weeks (avoiding the cost and patient barriers to early pregnancy multi-modal screening); at 24-28 weeks all will have this PlGF screening test, and those with normal values will be randomized to aspirin continuation vs placebo – as a non-inferiority trial with the goal of implementing feasible and equitable access to preeclampsia prevention.

Objectives:
The cardiac surgery workforce remains one of the least diverse in terms of racial diversity in medicine. For instance, in Canada, there has never been a single Black heart surgeon. Yet it is clear that diverse surgical teams reflecting the patient population they serve tend to better understand the patients’ social environment, ultimately providing better surgical care. The Next Surgeon aims to address this unmet societal and medical need by exposing Black and under-represented minority students to the field of heart surgery and medicine. In the first year, we focused on a cardiac surgery experience. In our second year, we grew the experience to include neurosurgery and emergency medicine.

Innovation:
We partnered with Toronto Community Housing and the Office of Inclusion and Diversity, Temerty Faculty of Medicine, University of Toronto, to identify under-privileged, predominantly Black high school students (N=30). The students came to St. Michael’s Hospital and the Michener Institute of Education at UHN once a week for 8 weeks to experience 1) mentorship talks by Black doctors and researchers that were aspirational and educational, 2) cardiac surgical anastomosis simulation 3) neurosurgery burr-hole drilling simulation, 3) emergency visit and CPR-experience (Figure). Importantly, all surgical mentors and speakers were Black or represented an under-represented minority group. For the final graduation event, we presented all participants (and their parents or guardians) with a diploma, hosted a Nigerian drum orchestra and featured talks by Mayor Olivia Chow, Member of Parliament Marci Ien, Justice Donald McLeod and Michael Pinball Clemens. For the evaluation scores, participants scored either agree (30%) or strongly agree (30%) that the experience met their expectations. For most participants (73%), their view of medicine and surgery was positively impacted by participation in the program.

Potential for Spread:
Our experience in the first and second iteration of The Next Surgeon were promoted on CBC news (https://www.cbc.ca/news/canada/toronto/the-next-surgeon-toronto-community-housing- 1.6762396 & https://www.cbc.ca/news/canada/toronto/racialized-high-school-students-career- surgeon-1.7116683). Most importantly, across the board, in both cohorts, the students had a very positive experience based on survey data. Our first cohort has already used this experience as a catapult to success in secondary school applications, many in the life sciences. Based on this success, we have been contacted by several Divisions at the University of Toronto who would like to take part in the next iteration of The Next Surgeon program. We have also been contacted by representatives of external institutions who would like to partner with us to start their own The Next Surgeon at their institutions.

Beyond the IF:
In Canada, the proportion of female staff has never exceeded 10%, suggesting a leaky pipeline for female cardiac surgical trainees. In many ways, cardiac surgery has been unwelcoming or unattractive to women – this is something that our profession and professional societies are actively working to change. We have already completed in a pilot project called The Next Woman Surgeon aimed at promoting cardiac surgery among women (Attachment). This is a partnership between St. Michael’s Hospital and Havergal College, an all-girls high school in Toronto. The pilot was a success and we plan to grow this program aimed at encouraging young women to consider heart surgery and other high-stakes surgical careers. We are actively soliciting funding. We have the support of the Office of Inclusion and Diversity, Temerty Faculty of Medicine, University of Toronto and the Equity- Diversity-Inclusion Taskforce of the Canadian Society of Cardiac Surgeons.

Background:
Night staff working on transitional care units in hospitals are tasked with ensuring the safety of patients affected by cognitive and/or mobility impairments. Supportive Smart Home technology systems can provide insights into the nighttime activities of residents.

Objectives:

• Adapt smart home technology for dementia care to a hospital setting
• Implement technology using both top-down and bottom-up change management techniques
• Success will be measured by a successful implementation and ongoing use by the nursing staff

Innovation:
The innovation is two-fold. First, the adaptation of experimental technology designed for home monitoring of nighttime wandering to a hospital setting. And second, the involvement of frontline staff in all steps of technology design, implementation and evaluation.

Industrial design students did a workflow analysis to help design the process for the use of the technology. Frontline staff defined the care elements that concerned them most: nighttime falls and nighttime wandering. The system, designed and operated by esprit-ai, was installed into the rooms of patients on a closed alternate level of care unit. The alarm parameters of the system were customized to each patient’s needs, as identified by the frontline staff.

Smart home technology can provide summaries of nighttime activities, leading to weekly/monthly comparisons in nightly bed exit behaviour. For physicians, this could be linked to medical changes or cognitive decline monitoring. Family members could feel more “connected” to the care of their loved ones by having access to such reports.

Potential for Spread:
This technology has applications in any hospitals that care for older adults with cognitive impairment. Long-term care facilities and retirement homes could also be interested.

Beyond the IF:
Two additional grants have followed this project:

• Ontario Bioscience Innovation Organization ($225K): partnership with Perley Health: nighttime wandering, falls risk, and reduction of nighttime sitters
• CABHI ($150K) – Bruyère Long-term Care: falls risk and reduction of pressure ulcers

Objectives:
We had several objectives which changed over the course of the project as the pandemic unfolded, and our understanding of COVID-19 management evolved. We used the Institute of Healthcare Improvement’s Model for Improvement to iterative improve each process, by using Plan-Do-Act- Study (PDSA) cycles. These included 1) Developing a virtual kiosk in the ED to assess lower acuity patients in the ED 2) Assessing the technical feasibility of remote assessment tools (such as virtual stethoscopes) to assess patients remotely at UHN 3) Stakeholder analysis in the ED and to gather and design a novel Virtual Emergency Department and 4) Improving access to emergency care through the launch of UHN’s first Virtual Emergency Department.

Innovation:
The development of the Virtual Kiosk, and by allowing providers to use it safely within the ED, we were able to experience using new technology for virtual care and provide feedback to help tailor the development of the Virtual ED. The Virtual ED pilot was successfully launched during the COVID-19 pandemic, making UHN one of Ontario’s first hospitals to provide patients with access to emergency care virtually. During the initial implementation, the pilot appears to be a safe and feasible model of care for select lower acuity patients. While the majority of patients were managed entirely virtually, a significant proportion required an in-person assessment for diagnostic testing such as imaging and bloodwork.

Potential for spread & future direction:
This project and funding supported the implementation and feasibility assessment of the model and initial pilot phase (12 months). Following the successful pilot phase, the project received funding from OH and support from the AFP grant (Project VIRTUE) to continue and scale the innovation. The model currently involves collaborative efforts between UHN, Sunnybrook Health Sciences, and Ontario Health to offer patients regionally coordinated access to virtual emergency care and is an integral part of the provincial virtual urgent care strategy. Future work is focused on exploring the following additional iterative improvements that would allow for our innovation to scale and spread further: 1) Utility of ordering out-patient testing to further minimize the need for in- person care, 2) Regional collaboration with Ontario Health and other hospitals in the Greater Toronto Area to offer a centralized portal for patients 3) Partnerships with Telehealth Ontario (811) for regionally coordinated triage. 4) Utilizing Nurse Practitioners for initial consultations (instead of physicians)

Objectives:
The RADICAL USe study aims to test the safety and effectiveness of using ultrasound, a type of imaging technology, to guide the placement of pacemakers and defibrillators without relying on X- rays (fluoroscopy). By using ultrasound to find veins and place pacemaker leads, we are reducing complications such as collapsed lungs, bleeding, blood vessel injury, lead dislodgement, and heart damage. Another goal is to reduce exposure to harmful radiation to healthcare providers and reduce the incidence of operator fatigue and musculoskeletal injuries due to the heavy protective gear. Overall, we aim to introduce a safer and more efficient technique for pacemaker implantation, especially beneficial in rural areas with limited access
x-ray.

Innovation:
This project introduces a novel approach at our hospital: the use of ultrasound for the entire pacemaker and defibrillator implantation process. It proved that the innovation is simpler, cheaper, and safer, thereby enhancing the safety and outcomes of the procedure by multiple operators. To disseminate this unique method, we published two manuscripts detailing the procedure to aid other clinicians in learning and adopting the technique. We completed the recruitment of 66 patients and submitted the final manuscript to the Heart Rhythm Journal. This innovation has the potential to be replicated in other regions, particularly remote areas in Canada and worldwide where X-rays are not readily available or are prohibitively expensive to install. I am currently in the process of collaborating with three other centers (Kitchener-Ontario, Sherbrooke-Quebec, and Nunavut province) to implement this technique.

Potential for Spread:
This innovative technique has the potential to be widely adopted by other hospitals and cardiac centers, not only within our province but also globally. Interest in learning this technique has been expressed by other centers and industry professionals, who have arranged visits to our University Hospital to observe the procedure firsthand. In regions with limited access to advanced imaging equipment, such as Northern Ontario, the Northwest Territories, and Nunavut in Canada, this technique can significantly improve access to safe and effective heart care and reduce costs of travel to tertiary health care facilities. Moreover, in low-income regions where healthcare costs are a concern, such as parts of Africa, this innovation can offer cost savings and improved safety. I have published twice to give details of the procedure so other operators can learn and arrange visits to the University Hospital.

Beyond the Innovation Fund:
Following the successful demonstration of this technique, this project has led to collaborations with Robarts Research Institute to develop a robotic arm to adjust the ultrasound probe, making it a solo operator procedure. Other institutions have arranged for individuals interested in eliminating X-rays to adopt this technique. A randomized control study is designed to evaluate precision lead placement for physiological pacing, such as left bundle branch area pacing. I am in discussions with other provincial health authorities to expand its use across their healthcare system as well as internationally.