Category: PSI Spotlights

“Historically this population has been underfunded, so it’s really important that PSI has funded dysvascular amputee research. We were happy to get this PSI grant, and it really built the confidence of the researchers in Ontario so that now we can work together and do bigger things.” – Dr. Amanda Mayo, Sunnybrook Health Sciences Centre

“We’re very grateful to PSI for funding this work because it really lit a spark and galvanized our research community, and it will ultimately improve the quality of life for the limb loss community.” – Dr. Sander Hitzig, Sunnybrook Health Sciences Centre

A PSI Foundation–funded grant to examine the health and quality of life of people with dysvascular limb loss has not only provided important insights into this understudied population but has also helped to develop the limb loss research field in Canada.

“Our overarching goal of is to develop collaborative research so that our patients do better, but to do this, we need to know how they’re doing and the resources they lack,” says Dr. Amanda Mayo, a physiatrist at St. John’s Rehab at Sunnybrook Health Sciences Centre who specializes in amputee rehabilitation. “This funding has allowed us to build a more cohesive and collaborative research program, but also work toward the greater aim of improving clinical outcomes for this patient population.”

Each year, approximately 1,500 people in Ontario have a major lower limb amputation due to dysvascular causes such as peripheral vascular disease or diabetes, making it the most common cause of lower limb loss in Canada. And the problem is expected to grow as the incidence of diabetes increases.

While any type of amputation can be traumatic, people with dysvascular limb loss face different challenges than those who lose limbs due to other causes, such as accidents.

“They’re a very vulnerable and frail population. They are usually older and tend to have a high number of comorbidities leading up to their amputation, in particular heart disease, arthritis and neuropathy,” says Dr. Amanda Mayo. “After the amputation, they’re at greater risk of complications, falls, depression and not being able to get back to community living.”

In 2018, Dr. Mayo and her co-principal investigator, Dr. Sander Hitzig, a scientist focused on aging and disability also based at St. John’s Rehab, received a PSI Foundation Clinical Research Grant to examine the health and quality of life outcomes of people with dysvascular limb loss – the largest study of its kind in Canada.

Study finds that physical and mental health decline post-amputation

In the study, the research team interviewed more than 230 people with limb loss about their physical and mental health, mobility, social connections and quality of life after amputation. They also interviewed 35 people from this group in more depth about their experiences of living in the community after amputation.

The study results showed some troubling trends. The people they interviewed experienced poor physical health, with an average of five comorbidities, most commonly diabetes, pain and high blood pressure. After amputation, mental health also tended to decline, and many people became more isolated; about one-third of interviewees expressed that they were lonely.

But the study also identified factors that could help people to cope better after limb loss; less impactful morbidities, a higher sense of self-confidence, and strong levels of social support were associated with better physical or mental health.

The interviews were done before the COVID-19 pandemic, but anecdotally it is likely that the pandemic has hit this population particularly hard.

“I think the pandemic has magnified how significant being socially isolated can be for anyone, and this was an isolated population before the pandemic,” says Dr. Hitzig. “We don’t have data about this yet, but they may have become more isolated and disconnected due to many of them being immunocompromised, and their physical health may have declined because of clinics being closed, not being able to get to the hospital, or surgeries being delayed.”

Results will help inform supports for vulnerable group

In addition to the interviews, Dr. Mayo and Dr. Hitzig analyzed data from a large cohort of Ontarians with lower limb amputations to understand their health care usage and the economic cost of dysvascular amputation. While this part of the project is not yet complete, early results suggest that people with limb loss are very high users of the health care system, visiting family physicians, specialists and emergency departments multiple times in the year following their amputation.

In fact, approximately 30% of people with dysvascular limb loss are admitted to long-term care and 30% die within two years of their amputation.

“These people are having significant health issues. We try to help them recover as best as possible through rehab, but many continue to decline,” says Dr. Hitzig. “There is a negative impact on the person and their family members, but there is also a health care system cost that we’re now hopefully starting to better understand.”

With a better understanding of the quality of life for people with dysvascular lower limb loss and the related social and economic costs, Dr. Mayo and Dr. Hitzig hope that the results from this project and their larger research program can be used to screen people who may be at greater risk of social isolation, as well as develop or connect people with programs to support their physical and mental health after an amputation.

“Predicting which patients are most at risk of isolation or not successfully integrating into the community would allow us to do more targeted rehab or pre-operative care,” says Dr. Mayo. “Looking at the data from this project, we see many opportunities for future collaborative research and ways to use the results to improve quality of life.”

As a community-based family physician, Dr. Carrie Bernard examines research questions that are directly relevant to her patients and practice.

“All of my research has come out of the clinical world, and for me, that’s what makes research meaningful,” says Dr. Bernard, physician at William Osler Health Centre in Brampton. “I see myself as firmly planted in the community as a physician. That is my home, and that is what matters to me. I am most interested in research that is going to help my patients in the long run.”

Since she started to undertake research projects over the last decade, she has partnered with researchers to work on projects ranging from humanitarian health care ethics to advanced care planning. One of her most recent projects, funded by a PSI Foundation grant for Medical Education Research that the Post-MD Level, focused on how ethics curriculum is taught to postgraduate family medicine trainees.

Dr. Bernard says that PSI’s support of family physicians and their understanding of their unique research approach helped her feel valued as a researcher.

“PSI felt like the right place to go for this funding because it represents who I am as a physician first and a researcher,” she says. “They understand and expect that as an MD, you will need to partner with a PhD researcher on your project. You’re not viewed as a lesser researcher because of that.”

New ethics curriculum aimed to increase confidence with challenging situations

Dr. Bernard’s transition to doing research was a gradual one. She had been practising as a family physician for several years when she volunteered on a humanitarian trip to northern Uganda with Médicins Sans Frontières (Doctors Without Borders). The experience left her with many questions about how to do humanitarian medical work ethically, but she realized she needed a research-focused education to properly answer the questions.

So, while continuing to practice family medicine fulltime, she earned a master’s degree in public health at the University of Toronto, focusing on global health and ethics.

Her master’s degree opened up new opportunities in academia, and in 2014, she joined U of T’s Department of Family and Community Medicine as Associate Program Director, Curriculum and Remediation. As part of her role, she began working with a team of physicians, ethicists and education experts to re-design how ethics is taught during family medicine residencies.

“One of the main reasons doctors run afoul with regulatory bodies is because of unprofessional behaviour and understanding how to manage these fraught and ethically challenging situations. It’s incredibly important to make sure you have strong ethical judgment to build trusting relationships with patients,” she says. Yet, “Family medicine trainees and even many practising family physicians feel underprepared and unconfident when it comes to ethics.”

Dr. Bernard worked closely on the new curriculum with Dr. Mahan Kulasegaram, director in the Office of Education Scholarship in the Department of Family and Community Medicine and an expert in learning sciences. They, along with the rest of their team, spent more than a year developing a new ethics curriculum that relied on family physicians – not trained ethicists – to teach the curriculum, as well as deliberately integrated ethical principles with the day-to-day work of family medicine.

“You can do a lecture on the principles of ethics, but if it’s not integrated within a realistic case that learners can understand in a clinical way, it seems remote,” she explains. “Our whole interest was really on grounding it in integration in family medicine and basing it on learning principles.”

Dr. Bernard and Dr. Kulasegaram then applied to PSI Foundation to evaluate the new curriculum. They worked with physician teachers at four teaching sites to teach the new curriculum, interviewed residents before and after they completed the curriculum, and evaluated the residents’ performance in the objective structured clinical examination (OSCE).

Positive pilot results help curriculum become self-sustaining

Dr. Bernard says that she and the team were “blown away” by the results. Residents from the pilot sites performed significantly better in a five-station OSCE focused on ethical issues compared to their peers who learned from the standard curriculum. And in the interviews, residents said they had greater awareness of ethical principles and could use a formal ethical deliberation process in challenging situations, which gave them more confidence to act and incorporate patients’ values into ethical deliberations.

Dr. Bernard says she was most pleased with what happened next: based on these results, the pilot sites not only continued using the new curriculum, but also supported the other training sites in implementing it. Having the curriculum become self-sustaining at the training sites was exactly the kind of result that the curriculum redesign team had hoped for.

“Now every single training site in our department is teaching it, and the original sites are acting as helpers,” she says. “We had hoped this would become a ‘train the trainer’ mentorship community of practice, and it just happened naturally that as these teachers became empowered and confident, they started teaching others.”

Having demonstrated these positive results in one department, the team hopes to generate more awareness of the curriculum results among physician teachers and residency program directors at medical schools across the country. In the long-term, she hopes that the curriculum will help more family physicians be more confident in their ethical deliberations and build positive patient relationships.

“Funding good educational research means we’re going to have good doctors in the future,” she says. “PSI’s support of this project is amazing because it directly affects the people – that is, the medical residents – who are going to make a difference in the future.”

“PSI Foundation It is one of the few granting agencies that funds clinical research. Its reviewers understand good science and good methodological design, but as clinicians, they also see the clinical problems. I feel that, as a clinician, I can be competitive with PSI because they understand that type of work.” – Dr. Joel Fish, plastic surgeon and Medical Director of the Burn Program at the Hospital for Sick Children, Toronto

Hypertrophic scars – thick and stiff severe scars that are often the result of burns – can affect children’s lives in many ways, interfering with a child’s growth, mobility and even confidence. And children with these scars haven’t had many effective treatment options to reduce the scar’s appearance and size.

But a new laser therapy may help to treat these scars, whether they are new or even several years old.

Dr. Joel Fish, a plastic surgeon and Medical Director of the Burn Program at the Hospital for Sick Children (SickKids) in Toronto, led a PSI Foundation–funded clinical trial that has provided some of the strongest evidence so far supporting the use of a new laser therapy to treat hypertrophic scars in children.

Lasers have been used in medical treatment for many years, particularly for cosmetic procedures, but recent research had suggested that two specific kinds of lasers, pulsed dye laser (PDL) and carbon dioxide laser, could be particularly useful for treating burn scars – even scars that are more than 10 years old.

“It’s one of the few therapies to come along in many years that has real benefits, not just on new scars but on mature scars, so it’s quite unique,” says Dr. Fish.

But more definitive research about the effectiveness of laser therapy, especially in children, was needed. Dr. Fish and his research team designed a clinical trial to determine whether laser therapy could improve hypertrophic scars in children, and received PSI funding in 2016 to conduct the trial.

Approximately 25 children with hypertrophic scars were treated with three laser therapy sessions over the course of a year. To determine whether the scars improved over the course of treatment, between sessions Dr. Fish and his team measured the scar’s height and thickness, stiffness, vascularity and colour, using validated subjective scar assessment scales and objective tools, such as conventional ultrasound and ultrasound elastography.

After all of the laser therapy treatments, the team found that the height of the scars improved, the thickness and colour improved, and the scars were less itchy, demonstrating that the therapy was highly effective.

“It really did have measurable effects, and not only were they measurable, the scars don’t go back to the way they were,” says Dr. Fish. “Once you achieve the scar being a little bit flatter or softer or less red or less itchy, it doesn’t go back.”

With these positive results, the team now plans to do further work to understand when treatment should start and how many sessions are optimal, as well as examine how the treatment works, all of which will help to refine the therapy.

SickKids has the largest pediatric burn program in the country by a large margin, and children from across the country have been treated in Toronto instead of closer to home. In fact, it is one of the few centres in Canada to use laser therapy to treat scars in children.

But Dr. Fish’s study, along with a handful of other trials, is generating interest in the health care community about the potential for this treatment. Directors of burn programs from different countries have learned from Dr. Fish’s team how to treat children with laser therapy to implement their own programs, and more hospitals across the country are beginning to invest in the technology.

“To our knowledge, this is the most comprehensive study to date that demonstrates that laser treatment leads to significant improvements in children with burn scars,” says Dr. Fish. “We hope that our findings will encourage other providers to invest in this valuable therapy for their patients.”

A clinical study supported in part through PSI has examined one of the most common complications faced by patients in critical care – diarrhea. Dr. Joanna Dionne, who is leading the Diarrhea, Interventions, Consequences and Epidemiology in the Intensive Care Unit (DICE-ICU) study, says that PSI support was essential to the study, which aims to improve care for patients experiencing diarrhea while in the ICU.

“My Resident Research Grant from PSI was truly transformative. It provided not only financial support, but also encouragement that my physician community in Ontario believed in me and this research,” she says. “This topic may not be ‘flashy,’ but diarrhea certainly affects many critically ill Ontarians, and we could certainly change care and impact our patients if we understood it better.”

Dr. Dionne is a gastroenterologist, intensivist and internist at Hamilton Health Sciences and assistant professor at McMaster University. As a trainee in critical care with her mentor, Dr. Deborah Cook, she realized that not much information was available about the incidence of diarrhea in the ICU and its causes.

This realization eventually led to the DICE-ICU pilot study, a prospective cohort study to establish the prevalence of diarrhea in patients in critical care, identify risk factors and document its consequences on clinical decisions and outcomes. The pilot study began with four sites in Ontario, then added two sites in the US. In 2016, Dr. Dionne received a PSI Resident Research Grant to expand the study to another three Ontario sites, which mean that nearly 900 critical care patients in total participated in the study.

Residents are the principal investigators on PSI Resident Research Grants, helping them gain key research skills to help prepare them for careers as independent clinician scientists.

“Early support will make or break someone’s career and will lead them to becoming a researcher or not,” says Dr. Dionne. “It’s not just about the science, but also getting experience with the administrative work of leading a study that is so vital for your career development. It’s absolutely fundamental.”

DICE-ICU study will provide foundational information about understudied topic

The DICE-ICU pilot study used three different definitions of diarrhea to estimate the incidence in critical care patients, which ranged from 40% to 77% depending on the definition. It also identified the risk factors most strongly associated with diarrhea, which included the number of days a patient was prescribed antibiotics. And, importantly, the study suggested that Clostridium difficile, which has been thought to be major cause of diarrhea in critical care patients, is actually responsible for only a small proportion of cases.

Based on these pilot results, Dr. Dionne initiated a larger DICE-ICU study, which includes more than 1,000 patients at 12 centres in four countries – the largest study of its kind in the world. The results will provide foundational information on the cause and impact of diarrhea in the ICU and may influence treatments that increase risk of diarrhea, such as antibiotic prescribing and enteral feeding practices in ICU patients.

In 2019, Dr. Dionne received a PSI Research Trainee Award, a two-year award that provides support to protect 75% of her time for research and allowed her to further the DICE-ICU study.

“The funding I received from PSI has been the building blocks of a research program that otherwise may not have been funded,” she says. “And importantly, PSI is able to support you as you grow as an investigator. It supports junior and early career investigators and has different programs to support you over time. That longitudinal support is absolutely transformative.”

Dr. Dionne says that it was challenging to get the DICU-ICU study underway, in part because there hasn’t been much interest in studying diarrhea in critical care patients or recognition of its clinical importance. But mentorship from Dr. Cook and support from PSI encouraged her to continue pursuing this question. This support inspires her to give back to younger trainees now and in the future.

“It makes me want to give back to my province, to PSI which has been incredibly instrumental to my career, and to give those opportunities to the next generation of young investigators,” she says.

Despite the challenges young clinicians may face, especially when trying to undertake a new research program, she encourages them to persevere to examine important clinical questions that can change patient care.

“It’s a true honour to work with patients and serve my community and my province, but when you’re working at the bedside, there’s always a question you cannot answer. That curiosity always drives me back to research,” she says. “As a physician, I can do my best for my patients, but as a researcher I can help patients that I will never meet, and I think that’s pretty powerful.”

A recent clinical trial, supported in part by PSI Foundation, is challenging the dogma around antibiotic use to treat community-acquired pneumonia in children. 

Physicians have traditionally prescribed a 10-day course of antibiotics, but this has been based more on convention rather than evidence. Dr. Jeffrey Pernica, a pediatrician and infectious diseases specialist at McMaster Children’s Hospital, recently led a clinical trial to determine whether a five-day course of antibiotics is as effective as the longer course.

“As medicine has transitioned to relying more on evidence rather than convention, we’re all trying to be more rational with antibiotic courses in order to make patient management plans that carry the most potential benefit and the least potential harm,” says Dr. Pernica. “As physicians, we all have a responsibility to make sure that when we use antibiotics, the courses we select are based on the best evidence so that our patients receive just the amount of antibiotics that they require – and no more.”

Potential antibiotic-associated harms include increasing rates of circulating antibiotic-resistant bacteria, medication costs to the families, short-term side effects, as well as longer-term health effects from disrupting the microbiome, including obesity and allergic disease.

Dr. Pernica first led a pilot study comparing a 10-day course of amoxicillin to a five-day course of amoxicillin for community-acquired pneumonia as part of his master’s degree in health research methodology. Based on the pilot study’s results, he received a PSI Foundation Clinical Research Grant in 2015 to expand the study and launch the SAFER (Short-Course Antimicrobial Therapy for Pediatric Respiratory Infections) trial.

“PSI feels like a collegial organization, and the grant reviewers are really my peers,” says Dr. Pernica. “They have the best interests of Ontarians at heart and a good idea of what studies are actually going to be useful for Ontario citizens, academics and clinicians.”

With PSI support, Dr. Pernica and his team recruited 281 children from six months to 10 years old who were diagnosed with pneumonia in the emergency departments at McMaster Children’s Hospital and the Children’s Hospital of Eastern Ontario. The children received either the full 10-day course of antibiotics or five days of antibiotics and five days of placebo and were followed closely until they were assessed two to three weeks after diagnosis.

The trial results, published in JAMA Pediatrics in March 2021, demonstrate that the short course of antibiotics was comparable to the standard course in treating children with community-acquired pneumonia. At 14 to 21 days after enrollment, 85.7% of children on the short course of antibiotics were “clinically cured” based on the study’s strict definition, compared to 84.1% of children on the longer course. The researchers then did a post hoc analysis to examine how many of the children clinically improved without needing additional antibacterials: 93.5% of children on the short course and 90.4% on the longer course fit this criteria. Taken together, the results suggest that the short course of antibiotics is just as effective as the longer.

Dr. Pernica says the trial did not require any special tests for physicians to order or onerous follow-up for patients, reflecting real-world conditions of how pneumonia in children is diagnosed and treated, which should allow the results to be quickly integrated into practice. 

“The patients in this study are very similar to patients that doctors see every day in Canadian emergency departments and diagnose with pneumonia,” says Dr. Pernica. “For that reason, we think that this evidence is generalizable to the vast majority of children being diagnosed with pneumonia in Ontario emergency departments and will be of practical use for Ontario-based physicians.” 

Given the urgency and scale of the challenge of antibiotic resistance, Dr. Pernica and his team are now focused on knowledge translation to incorporate the results into prescribing practices. They are working with research groups such as Pediatric Emergency Research Canada to integrate the results into practice and reduce antibiotic use where possible.

“Antibiotic resistance has become so important, not just in other places in the world, but here in Canada as well. We all need to do our part to use antibiotics responsibly so that we are still able to control bacterial infections in our population,” says Dr. Pernica. “It’s going to be critical to make sure that clinicians in Canada use only as much antibiotics that are needed to cure a patient, but no more.”

“PSI’s Resident Research Grant gives you complete ownership over the project, and you gain important skills in grant writing, finances, and leading projects. For someone like me, who is interested in a career in research, these elements are going to be important in my future, and having a resident-focused grant gives you some of those skills that are important to any scientist.” – Dr. Fahima Dossa, general surgery resident, University of Toronto

Dr. Frances Yeung, a former pediatric resident at London Health Science Centre (LHSC), says her PSI Resident Research Grant was not only critical for her resident project, but also for putting her on the path of a research career.

“It piqued my interest in research. Prior to this, I didn’t know if I wanted to incorporate research into my future career,” says Dr. Yeung, now a clinical fellow at The Hospital for Sick Children. “Now I have more confidence and the knowledge to do so.”

Dr. Yeung led an ambitious, methodologically intense project for any resident – a clinical trial comparing two approaches to maintain a peripheral intravenous catheter (PIVC) in children.

PIVCs are essential for delivering fluids and treatments into a patient’s bloodstream, and because they can be painful and time-consuming to insert, health care providers try to make these devices last as long as possible. Two approaches are currently commonly used: “to keep vein open” (TKVO), which is a continuous low infusion of fluid through tubing, and a saline-lock, which “locks” a small amount of saline into the PIVC and requires no other tubing.

Dr. Yeung and her supervisor, Dr. Sepideh Taheri, saw that there was a lack of guidance around which method to use. Different countries, provinces and even centres differ in their preferred method.

For example, saline-lock is commonly used in Manitoba, where Dr. Yeung did her first-year residency, and in the United Kingdom, where Dr. Taheri worked prior to coming to Ontario. But at the Children’s Hospital at LHSC, where they worked together, TKVO was used most often.

In reviewing the literature, they found that very little research had been done to determine which approach should be used. Previous research had been based in the neonatal intensive care unit (NICU), but no studies had been done in the pediatric population.

The research in the NICU suggested that saline-lock made it easier for parents to care for their babies and reduced the risk of strangulation from tubing, reduced the burden on nurses to check the PIVC, and likely resulted in cost savings, but the big question – how long each approach maintains the PIVC in pediatric patients – was unclear.

Clinical trial is recognized nationally and changes practice locally

With a PSI Resident Research Grant, Dr. Yeung led a clinical trial comparing TKVO and saline-lock to determine how long each method maintained the PIVC in children from newborns to 17 years old. For three months, every child who was enrolled in the study received TKVO. This was followed by three months where every child who was enrolled had a saline-lock. The research team measured how long each PIVC remained patent, as well as collected data on complications and patient and caregiver satisfaction.

Importantly, they found that the two approaches were not significantly different in how long they maintained the PIVC, complications from PIVC, and patient and caregiver satisfaction.

“It was an important result that there was no difference between the two in the length of time that the IV lasted,” says Dr. Yeung. “And we know that saline-lock has those additional benefits, so hopefully other pediatric centres across Canada will consider moving toward using it.”

The study results have strong potential to help guide physicians’ decision-making, and Dr. Yeung and Dr. Taheri have presented the results at hospital rounds, conferences and national webinars to increase awareness. In LHSC, they noticed that practice is already starting to change, with more pediatricians and nurses choosing to use saline-lock for their patients.

In particular, Dr. Yeung presented at the National Pediatric Resident and Fellow Research Competition in 2019 and won the resident category. Her research stood out, in part, because of the more intense research methodology involved in a clinical trial.

Support from her supervisors in developing the trial and from PSI to fund the trial were key to her success. PSI Resident Research Grants are unique in that they require the trainee to be the principal investigator on the grant and perform the majority of the research, preparing them for future careers as clinician scientists.

“A clinical trial can be difficult to accomplish and requires so many resources, and many residents take on projects that are less intense in their methodology. The PSI grant definitely gave me more confidence in completing my own research and working through the methodology with my supervisors,” she says.  “Before this trial, I had never been involved in such a big study, and it has helped me develop stronger skills in research methodology and clinical trials. Now I have the confidence to move forward in this career.”

“Opportunities such as the Resident Research Grant help residents gain the skills necessary to participate in crucial research and build excitement to continue pursuing research projects when they move on in their careers. The more that trainees can immerse themselves in research during their training, the higher the probability that they will incorporate such skills into their full-time careers.” – Dr. Sameer Shaikh, Joseph Brant Hospital, Burlington

Resident-led research supported by PSI Foundation is drawing attention to the most common and effective forms of medical training in end-of-life care. A better understanding of current training may suggest new learning approaches to help trainees become competent and comfortable with these important skills.

Research has found that 50 to 70% of Canadians die while in hospital, many in high-dependency units such as the ICU, so physicians are often involved with patients and their families during the patient’s final moments.

“In my opinion, taking care of someone at the end of their life is just as important as knowing how to resuscitate a sick patient,” says Dr. Sameer Shaikh, an ICU and ER physician at Joseph Brant Hospital in Burlington. “Knowing how to have these essential but difficult conversations with patients and their loved ones ensures that we are truly serving our patients based on their own values and wishes and that the resources we have are not being misused.”

The Royal College of Physicians and Surgeons of Canada outlines nine end-of-life care objectives for adult critical care medicine trainees (also known as fellows), including pain and symptom management, withdrawal of life-sustaining therapy, and bereavement and counselling. “But end-of-life skills are not necessarily part of the traditional mindset of an early critical care trainee,” says Dr. Samantha Arora, a critical care physician at Thunder Bay Health Sciences Centre. “Most often, fellows are focused on the procedural skills and expert knowledge that they have to acquire, and end-of-life skills can become lost.”

Dr. Shaikh and Dr. Arora were training in critical care at McMaster University when they applied to PSI Foundation for a Resident Research Grant to examine critical care fellows’ end-of-life training and their comfort with these skills.

PSI’s Resident Research Grant is a unique and valuable opportunity for medical trainees, as it requires the resident to be the principal investigator and perform the majority of the research, preparing them for future careers in research. “The onus for the research is on the resident, and it becomes their responsibility in a different way than if they are simply part of the team,” says Dr. Arora. “When you’re involved with the granting agency, you’re part of the conversations around the entire study, and it really helps build those research skills.”

In 2018, PSI funded the ESPRIT (End of Life Skills and Professionalism for Critical Care Residents in Training) study , a national survey of 78 critical care fellows and 12 program directors (PDs). The survey asked about how end-of-life skills are commonly taught and how comfortable fellows are with the Royal College’s end-of-life care learning objectives. In some ways, the survey provided data that confirmed Dr. Shaikh’s and Dr. Arora’s own experiences: fellows and PDs reported that informal forms of teaching, such as direct observation, advice from attending physicians, self-reflection and even voluntary feedback from nurses, were the most common forms of teaching. While these informal methods were often reported as effective, Dr. Arora says, “it does raise questions about how well we understand how much trainees actually know about end-of-life skills and how we are evaluating their knowledge.”

The survey also highlighted that fellows and PDs did not always perceive the learning experience of certain skills in the same way. For example, trainees reported being quite comfortable with pain and symptom management, while most PDs did not feel this skill was taught effectively. The largest discrepancies related to organ donation skills. While most PDs thought these skills were taught effectively, only 65% of trainees were comfortable identifying candidates for donation after cardiac death (DCD) and less than half were comfortable conducting the DCD process.

“Just because PDs perceive a skill as being taught well doesn’t mean that trainees are more comfortable performing that skill,” says Dr. Shaikh. “The more we understand these discrepancies, the more we can bridge the gap between curriculum design and trainee requirements.”

The study’s results were particularly timely, as the Royal College was about to implement Competency Based Medical Education, and the survey suggested gaps where fellows could use additional training. For example, specialized rotations with faculty experts in palliative care or with agencies such as the Trillium Gift of Life Network could expose fellows to specialized knowledge.

The ESPRIT survey was completed well before the COVID-19 pandemic, but the current crisis has heightened awareness of the importance of effectively teaching end-of-life skills. “In some ways, this pandemic is the ultimate training experience for critical care trainees when it comes to knowing how to manage end-of-life care in the ICU,” says Dr. Shaikh. “I hope that our trainees are using this experience to enhance their skills and recognize how important an area this is within their training.”

PSI Foundation often funds large collaborative teams to tackle challenging research problems, but a newly funded team through the PSI COVID-19 research grants has a key difference.

Dr. Robert Wu is an internist at University Health Network with an interest in informatics to improve patient care, and Dr. Andrea Gershon is a respirologist at Sunnybrook Health Sciences Centre who uses large health administrative data sets to study health outcomes of people with lung disease. They are two of the principal investigators in a large team developing cutting-edge wearable patient monitoring technology.

But their partnership extends beyond research. The pair first met in medical school and have been married for more than 20 years.

Drs. Wu and Gershon have rarely collaborated on research over the years, but about five years ago they had an opportunity to combine their overlapping interests on an innovative project. They began to collaborate with Dr. Eyal de Lara, a computer scientist at the University of Toronto, and a large team of clinicians and computer experts to develop an app and smartwatch system that can monitor and detect exacerbations in COPD patients.

The work was progressing well, but it ground to a halt as Ontario entered a state of emergency in March due to the COVID-19 pandemic. The project team realized that the groundwork they had already done for the COPD app could be applied to COVID-19 and quickly pivoted the research. “There was a lot of enthusiasm for the idea, and the team sincerely wanted to do something that would help people through a difficult time,” says Dr. Gershon. “I think people were happy to have something meaningful to focus on.”

Their new PSI Foundation COVID-19 research grant, which includes Dr. de Lara as the third principal investigator, will support the team’s work to develop at-home monitoring technology for COVID-19 patients and a model to predict those patients at highest risk of deterioration. Dr. Wu says that PSI’s quick response to the pandemic has been critical, even as cases started to decline at the beginning of the summer. “The timeliness is really important. It lets us prepare for the next wave that may be coming,” he says. “We can make sure that we have all the systems set up, and the algorithms and app further developed so we can be ready to use it for the next wave.”

At the height of Ontario’s COVID-19 diagnoses in the spring, some physicians and health care teams were following as many as 50 or 60 COVID-19 outpatients at one time. Monitoring these patients using traditional systems – reviewing individual charts and making regular phone calls to patients – was time consuming and unsustainable in the long term.

At the same time, physicians have a hard time predicting which patients are at the highest risk of deterioration and needing hospital care. Dr. Wu says that the presence or absence of symptoms does not necessarily correlate with oxygen saturation and disease severity.

The team is adapting their COPD app for patients to report symptoms and measurements such as temperature and oxygen saturation. Smartwatches will continuously measure physiological measures such as respiratory rate, heart rate and cough. By integrating these measures and patient outcomes, they aim to develop a model to predict which outpatients are at highest risk of deterioration so they can be monitored more closely. They are also developing a dashboard for physicians that will incorporate real-time data from patients and the prediction model to help physicians monitor large numbers of patients at one time and flag those at highest risk.

Dr. Gershon, who was a PSI Foundation Graham Farquharson Knowledge Translation Fellow from 2013 to 2015, credits PSI and the fellowship with giving her the time to allow her to pursue this field of research. “Working with wearables and technology is high-risk research, and I’ve been really impressed that PSI is willing to take those risks,” she says. “Their willingness to look at the future and invest in technology with a focus on patient care is admirable.”

Collaboration from a variety of experts has been key to the team’s efforts, and Drs. Wu and Gershon have appreciated the contributions of the team to the project. And the pair has particularly enjoyed the opportunity to work on this research together during this unusual and challenging time. “There’s highs and lows like any research project,” says Dr. Gershon, “but it’s always nice to go through those highs and lows with someone else.”

“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.”