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.”

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.”

Research from a PSI Foundation–funded team has led to the development of a first-of-its-kind assessment of seniors’ biomedical and social vulnerability. The Frailty and Vulnerability Evaluation (FAVE) tool, developed by Dr. Ross Upshur and his team at Bridgepoint Active Healthcare and the Department of Family and Community Medicine in Toronto with funding from PSI Foundation, is a step towards higher quality care for seniors.

Dr. Upshur’s career has largely been focused on senior care, starting with electives as an undergraduate in medical school, followed by several years as a primary care physician in a rural area with a large senior population. In recent years of his research career, he and his team have been interested in developing tools to help physicians in family practice manage the complex health care needs of seniors.

They identified that while certain aspects of seniors’ health were becoming better understood, there was still a significant gap – social isolation. “There’s growing interest and recognition from the health system around frailty,” says Dr. Upshur. “Frailty is important, but not the whole story.” Yet, no clinical tools in primary care looked at both frailty and social vulnerability, so he and his team, with input from an expert advisory committee, developed one.

The new tool, FAVE, asks seniors about their health and functional abilities, but importantly, also asks about their social wellbeing, including their loneliness, living arrangements, feeling of safety and economic insecurity. “People are now talking about loneliness and isolation as an issue,” says Dr. Upshur. “A primary care physician might notice that a patient might have issues with loneliness and vulnerability, but collecting this information has not been systematic.”

With funding from PSI Foundation, the team validated FAVE and compared the performance to existing measures, such as the frailty score and physician judgment, to determine if it is a reliable predictor of an individual’s health and wellbeing.

More than 260 patients from 10 Family Health Teams from urban, suburban and rural practices completed the tool. Seniors completed the FAVE assessment on paper or electronically prior to an appointment with their family physician. The team also asked the family physician for an assessment of the individual’s frailty and wellbeing, blinded from the patient’s score on the tool.

They found that patients thought the survey was user friendly, and importantly, that FAVE scores correlated well with seniors’ self-reported health, as well as physician assessments and frailty scores.

To understand whether FAVE is a good predictor of an individual’s future health, the team is now looking at patients’ charts one year after they complete the tool, particularly to examine the patient’s total number of health care transitions (such as being admitted to the emergency department, long-term care or a return home), and the total number of days spent at home. The analysis is currently underway but will help determine whether FAVE, physician judgment, the frailty score, or a combination is the best predictor of a patient’s future health care transitions.

Dr. Upshur notes that PSI Foundation plays an important role in this type of research. “It can be difficult to get funding for small-scale projects that engage local partners, but PSI Foundation is a strong supporter of this type of research,” says Dr. Upshur. “They focus on research that is meaningful to clinical practice.”

As Ontario includes an already large and growing population of seniors, Dr. Upshur hopes that FAVE will help primary care physicians care for both the health and social needs of seniors. “The tool is just one component of a systematic approach for seniors in the community by primary care physicians,” he says. “It’s an important step towards more comprehensive, appropriate, compassionate and high quality care for seniors.”