“PSI Foundation has always been supportive of this kind of research. They give you the freedom to study the things you know are important, but that other agencies may not see as under their purview. They trust you as a clinician that you know what’s important.” – Dr. Carol-anne Moulton

Checklists have been praised as a simple and cost-effective way to improve patient safety. But can they be implemented in an operating room (OR) without considering a hospital’s surgical culture?

A landmark paper published in 2009 demonstrated that a simple surgical safety checklist (SCC) cut morbidity and mortality around the time of surgery by about one third. Within just a few years, governments in many jurisdictions – including the Ontario provincial government – required all hospitals to implement a similar checklist in their operating rooms. Very quickly, the SSC shifted from a recommended tool designed to improve patient care to a mandatory policy, deeply enmeshed in hospital politics. Dr. Carol-anne Moulton, a staff surgeon and medical director of the OR at Toronto General Hospital and Princess Margaret Cancer Centre, had some questions about the SSC, the claims that had been made about its impact on patient care, and the ways its implementation had – or had not – changed practice in the OR over the past decade.

“There’s an assumption that if we say something is for patient safety, people will just do it, but this isn’t the case,” she says. “Surgeons and medical staff care about patient safety, but we need to question how we bring safety initiatives into a culture or institution so they work the way we want them to.”

Using her research experience in studying surgical judgment, Dr. Moulton, along with sociologist Dr. Elise Paradis and anthropologist Melanie Hammond Mobilio, studied the culture of the operating room with respect to the checklist. With PSI Foundation funding, they focused on the practices at one Ontario hospital, observing surgeries, interviewing operating room team members, and conducting staff surveys.

Their findings revealed a lack of clarity around what it means to “do the checklist.” For some, the checklist is understood as the physical piece of paper (i.e., the tool itself), while for others, the checklist is understood more broadly as a practice loosely tied but not limited to the physical checklist. This key finding raised further questions around compliance rates. Despite the study site having a reported compliance rate of nearly 100%, the physical checklist was rarely used. Instead, OR teams used different processes – often dependent on the expertise and preferences of the surgeon or the workflow of the surgery – that acted as some version of the checklist, though without the standardization one might expect from checklist-based practice.

They also found that the checklist itself did not inherently foster teamwork, despite the claims made by some checklist advocates. Surgical culture, including existing power dynamics and institutional structural issues (e.g., staff changes over a case due to breaks), limited the sense of a cohesive team in ways that could not be easily corrected by a single intervention. And the lack of clarity around exactly what “doing the checklist” meant, coupled with a reporting system designed to report quantifiable compliance rates to the Ministry of Health and Long-term Care, added to the complexity around a seemingly “simple” intervention.

The qualitative data the team collected during the study helps to describe some of the main challenges surrounding implementation of the checklist. “The study highlights the need to think about these issues at a deeper level,” says Dr. Moulton. “Understanding the culture is critical and doing something about it is really slow and hard. There is no quick fix, and hospitals need to dedicate resources to actually improving the situation.”

Despite the challenges of checklists, Dr. Moulton believes that they can be effective tools to improve patient safety – if the culture of the OR is considered during design and implementation. She hopes that her research keeps the conversation about the SSC and its value going among OR personnel and hospital leadership.

“The work challenges people to see that we may not be as good as we say we are,” she says. “There’s nothing wrong with declaring it, and we have to understand it if we’re going to get better.”

Dr. Kimia Honarmand is currently a critical care physician at London Health Science Centre. She led research during her critical care fellowship training with supervisor Dr. Ian Ball to survey health care providers and the Canadian public about their support for two controversial organ donation protocols that may be used after circulatory determination of death. The surveys not only demonstrated support for organ donation, but also kick-started an entire program of research.

Two protocols may be used for cardiac donation after circulatory determination of death (cardiac DCDD):

• Direct procurement and perfusion (DPP): the heart is removed from the donor after circulatory determination of death and placed in a machine where its activity is restored until transplantation
• Normothermic regional perfusion (NRP): circulation and cardiac activity are restarted in the body after circulatory determination of death, although blood supply to the brain is interrupted, and the heart is then removed from the donor

While these techniques have the potential to increase the number of organ donors, they have yet to be conducted in Canada, partly due to concerns about their acceptability to the Canadian public and health care providers.

PSI: What did the Resident Research Grant allow you to study?

Dr. Kimia Honarmand:

Health care providers and experts in transplantation have expressed concerns about these two approaches being accepted in Canada. Would the public and clinicians be comfortable with these protocols? Would there be any ethical concerns? Would there be any backlash? The only way to find out is to ask people.

We developed two national surveys, one for health care providers who manage organ donors or transplant recipients and one for the general public, to ask about their support for these protocols. The surveys went through rigourous pre-testing and pilot testing to ensure they were accurate and comprehensive.

PSI: What did the surveys find?

Dr. Kimia Honarmand:

The surveys demonstrated that the majority of health care providers and Canadians are supportive of the protocols. Nearly 90% of health care providers and 84% of the general public supported DPP, and 71% of health care providers and 66% of the general public supported implementing NRP.

We found it interesting that even though we thought the NRP protocol would receive next to no support, the majority of respondents in the general public were supportive. They had a lot of positive sentiment toward organ donation in general, even the controversial protocols.

PSI: What are the next steps for the research?

Dr. Kimia Honarmand:

The funding was relatively small, but it spawned an entire program of research with the goal of ensuring the implementation of cardiac DCDD is done in a manner consistent with Canadians’ values.

Since the surveys were completed, we have published three articles about the surveys, presented at a national forum led by Canadian Blood Services and Trillium Gift of Life Network and presented at the Canadian Critical Care Forum.

Our survey findings have generated a lot of interest in the critical care community. At the meetings, a lot of the conversation kept referring to the survey findings. There was widespread recognition that these findings are important in making sure that if we’re going to implement these protocols in Canada, we do it in a way that respects Canadians’ values.

And we have successfully applied for funding from Canadian Blood Services to delve further into these topics. We are interviewing health care providers and the public to understand their perspectives and find the best way forward to implementing cardiac DCDD in Canada.

PSI: How did this research grant contribute to your career?

Dr. Kimia Honarmand:

This program of research that has evolved from the PSI grant has become the primary focus of my research career. Since finishing my medical training, I’ve continued to be engaged in this topic, leading this program of research with mentorship from Dr. Ian Ball and identifying ways that we can mitigate any concerns about these protocols and find the path forward to implementing them in Canada.

I owe a lot of the successes I’ve seen in last couple of years to that relatively small grant. This research has become a prominent feature of my career. It has helped drive my career path in a much clearer direction and solidified my interest in doing research in organ donation and transplantation.

PSI: Why is it important for PSI Foundation to fund resident research?

Dr. Kimia Honarmand:

This kind of opportunity, even if it’s a small grant, can really help shape the career of an early career, keen researcher. When you’re training, you’re often interested in so many different topics and you have to lean into one; having an area of research where you’re financially supported and where you have the opportunity to lead research that actually has impact on the community can help an early career researcher feel confident that they are on the right career path.

A grant like this helps a early career researcher solidify where to go with their career. It’s an important validation that what you’re doing is important to society.

“I wouldn’t have been able to do this research without PSI. It was important for me to know that colleagues recognize and value this work.” – Dr. Fiona Kouyoumdjian

Dr. Fiona Kouyoumdjian’s research is helping to increase the visibility of a population that is often kept out of view – people who experience incarceration. Her PSI Foundation–funded study provides a foundation of information about the health care needs and health care use of this group of people, which until now, has not been well understood.

From her part-time role as a family physician at a provincial correctional facility, Dr. Kouyoumdjian knows firsthand that this population has complex health care needs, yet there has been little research about their health care use.

“I see a lot of opportunity to improve health care for this population in both correctional facilities and in the community,” she says. “There’s a lot to be done to understand imprisonment in Canada and to improve health care and the health status of this population.”

She received PSI Foundation funding in 2016 to study health care use by people who have experienced imprisonment, both during their time in custody and after their release into the community.

Dr. Kouyoumdjian and her team linked correctional data from the Ministry of the Solicitor General with health administrative databases. With these datasets, they followed the population of people released from provincial correctional facilities in 2010, which was more than 50,000 people, comparing their health care needs and use with the general population.

The team found that people who experienced incarceration had higher rates of health care use overall compared to the general population, including higher numbers of visits to primary care, other ambulatory care, and emergency departments, and higher rates of hospitalization.

Dr. Kouyoumdjian says that the baseline health of this population is worse than the general population, and they experience higher rates of health issues like injuries and overdoses, particularly around the time of release – so it may not be surprising that their health care use is high.

Notably, they found that a large percentage (40%) of people who had been incarcerated did not see a primary care physician in the two years after release, which is particularly troubling considering the higher health care needs of this population. “People have a lot of competing priorities when they leave provincial prisons,” she says. “Taking care of your health can be challenging when you’re dealing with urgent issues like finding housing, restarting your benefits, and trying to rebuild relationships.”

By showing that the time of release from prison is particularly challenging, Dr. Kouyoumdjian says that her research suggests that there are opportunities to provide interventions that support people at this time, for example programs that link people released from prison with primary health care. “We need to think about opportunities to support health more broadly,” she says. “It’s a shared responsibility between community health care and correctional facilities.”

Dr. Kouyoumdjian adds that this study is just a first step in understanding the needs of this population, but that it has strong potential to inform interventions. “This is a population with a substantial burden of disease and substantial health care needs,” she says. “We need to invest resources in their health care.”

“PSI funding was important to our study, and it allowed us to achieve our goals. We could work with vendors to create the interventions and hire a research assistant to do data collection, which made the study more robust.” – Dr. Jennifer Tsang

Dr. Jennifer Tsang, an intensivist at Niagara Health, would like to see more community hospitals in Ontario increase their research capacity, and as a researcher herself, she understands the importance of dedicated funding allocated to community research.

She says that programs like PSI’s Healthcare Research by Community Physicians Grant are essential. “It’s challenging for community hospitals to apply for funding and compete against an academic centre. The academic hospital and staff often have better track records of research that give them an advantage,” she says. “Having separate community health research grants really helps individuals like myself who are leading research in a community setting.”

Dr. Tsang received a Healthcare Research by Community Physicians Grant from PSI Foundation to develop interventions to improve adherence to pain, agitation and delirium (PAD) guidelines, specifically the frequency of assessing patients for PAD, in the intensive care unit at Niagara Health.

PAD clinical guidelines recommend screening for pain and agitation four times per 12-hour shift, and once per 12-hour shift for delirium. But Dr. Tsang saw that community centres are often behind in adopting guidelines.

She and her team developed an e-learning module targeting nurses and laminated reminder tools placed at each bedside, and they reminded physicians to talk about PAD during multi-disciplinary rounds with a note left on the computer on wheels. They also developed interventions targeting family members: a team of volunteers interviewed family members about the patient to develop a personalized approach to managing PAD, and pamphlets and a video provided information about delirium for family members. Finally, they displayed posters in the ICU about delirium, its importance and the team approach to managing it.

Together, the interventions increased the number of patients who were screened according to the guidelines for pain and agitation, though the delirium assessment did not change. The study did not examine why delirium assessments did not change, but it could be due to the greater time required for delirium screening or the belief that screening will not change how the condition is managed.

“Sometimes we try complicated interventions, but sometimes simple things like these reminders have the biggest impact,” she says. “Also, in my community hospital, I don’t have the resources of an academic hospital. We had to be very practical.”

Dr. Tsang notes that while there may be challenges in adopting guidelines at a community hospital, the study shows that it is possible using practical, low-cost interventions. Involving frontline staff in the design of the interventions and as “local champions” to encourage and support staff during implementation, as well as approaching the interventions through the lens of quality improvement, all seemed to be important in increasing adherence to PAD guidelines in a community setting.

Dr. Tsang says that her grant is just one example of important, relevant research done in a community setting, and she would encourage more centres to pursue projects relevant to their community.

“Most community centres have primarily focused on delivery of clinical services rather than conduct of research programs or projects, but I think this is starting to change,” she says. “We need more community hospitals embarking on research, and PSI funding is critical for making that happen.”

“PSI has a good reputation of supporting studies that have impact on daily practice. It supports practicing physicians’ research that will have immediate impact on the practice of their colleagues.” – Dr. Marcel Ruzicka

New automated blood pressure monitors have significant advantages over older monitors. One such advantage is the ability to take blood pressure measurements without medical personnel in the room, eliminating the possibility of “white coat phenomenon,” which is thought to result in higher readings when medical personnel are present. New PSI-funded research suggests that different ways of taking automated measurements may need interpretation if they are to be used to accurately diagnose and manage hypertension.

“The circumstance under which blood pressure measurement is taken, more so than the technique, is crucial for estimating blood pressure,” says Dr. Marcel Ruzicka, a nephrologist specializing in kidney-related hypertension at The Ottawa Hospital Research Institute. The differences in measurements among techniques can be large enough that they may affect a physician’s decision about whether a patient needs to be treated for hypertension.

“It’s not a question of which method is best,” says Dr. Ruzicka. “Our study provides evidence that different blood pressure targets might be appropriate if you use a different measurement method from the technique used for the published blood pressure target.”

With a PSI Foundation Clinical Research Grant, Dr. Ruzicka and his team compared different ways of measuring blood pressure to look for differences in the measurements. A total of 78 patients completed the study, during which their blood pressure was measured on two consecutive days using different methods: using automated devices both attended and unattended by a nurse, and using an ambulatory blood pressure measurement device that took measurements every 20-30 minutes over a 24-hour period.

Their results suggest that resting blood pressure readings were not significantly different whether the measurement was fully or partially attended, or even unattended. Most importantly, they found that resting blood pressure – regardless of whether medical personnel were in the room or not – was significantly lower compared to the 24-hour average, suggesting that the ambulatory measurement may be crucial for hypertension diagnosis and management.

“The ambulatory measurement includes everything in your life, and for most people, there aren’t many times when you sit alone and quiet, as you do with resting blood pressure,” says Dr. Ruzicka. “In a way, this result is not surprising.”

The study is not meant to discourage practices from using any particular technique. Instead, Dr. Ruzicka says that it’s more important to understand that the techniques yield different results, and physicians need to understand these differences when diagnosing hypertension.

“This information is crucial for family physicians and specialists in order to provide them with a guide of how to interpret these measurements,” he says. “We hope that eventually these results will be reflected in the guidelines [for diagnosis and management of hypertension].”

“Because PSI is geared toward physicians, there’s almost an unwritten understanding of why you’re doing the research and that it’s for the end goal of treating our patients better. We don’t have to prove that our research has clinical relevance.” – Dr. Kim Wong

Total knee replacement is a common procedure done in many hospitals, and it is known to be associated with a significant amount of post-operative pain. Many interventions exist to address this pain, but since a myriad of techniques can be used, choosing the optimal technique can be a source of much discussion in the operating room. Local practices vary based on the location and time of team members’ training, and orthopedic and anesthesia teams may have different views of the best approach to use.

“Everyone seems to have differing opinions about which analgesic intervention to use perioperatively,” says Dr. Kim Wong, an anesthesiologist at Health Sciences North in Sudbury. “But at the end of the day, everyone wants the patient to go home with as little pain as possible and as soon as possible.”

Evidence on the subject has been definitively inconclusive so far, with mostly small, comparative single intervention studies. Dr. Wong saw the need for a larger interdisciplinary study that compared different combinations of interventions used in real world practice on patient outcomes, with the goal of providing clarity on the best approach to use.

She received a grant from PSI Foundation to lead a five-arm randomized blinded trial that involved both the orthopedic and anesthesia departments at Health Sciences North. They compared different combinations of three pain management interventions used before and during total knee replacement surgery: intrathecal morphine, femoral nerve block (a regional anesthetic injected into the upper thigh) and periarticular infiltration (local anesthetic and anti-inflammatory injected around the knee joint). They evaluated whether intrathecal morphine alone, different pairs of the interventions or a combination of all three affected time for patients to reach discharge criteria, their pain scores and their narcotics needs after surgery to control pain.

The study team found that all of the arms of the study met discharge criteria, with patients being discharged by the afternoon of the second day. But further analysis showed that any combination of two interventions had better pain outcomes than intrathecal morphine alone, though the combination without intrathecal morphine resulted in less itchiness. Surprisingly, the combination of three interventions did not result in significantly better outcomes.

“I hope the study gives surgeons and anesthesiologists comfort that they can choose the interventions that they do best, as long as they provide two,” says Dr. Wong. “In my own clinical practice, I can tailor my approach to accommodate a patient’s individual medical history with the comfort of knowing that I’m not placing them at a disadvantage of getting out of the hospital faster or with less pain.”

Dr. Wong says that it was ambitious to lead a five-arm trial with enough statistical power to be clinically relevant, and the study team did have challenges with recruitment. As a result, PSI Foundation funding was essential to the study’s success. “It allowed us to address the challenges without having to worry about stopping the study or not having a powered study that would lend less credibility to the results,” she says. “The funding allowed the financial buffer to reflect the realities of clinical research.”