Conducting Research as a Surgical PA
My interest in Research
My interest in research is around health promotion. I believe PAs play an important role in being patient advocates, and health advocates essentially. As practicing PAs, I know many of us face current processes and clinical frameworks in our workplaces that can be modified to help improve patient outcomes. I think PAs are highly capable of identifying those opportunities for improvement and working to enhance quality of patient care.
Personally, I’m always looking for opportunities and ways to improve patient safety and quality of care that I deliver. Overall, a lot of the projects that I’ve done to date are around quality improvement. I’ll talk about the two that our group is currently working on right now.
Research Project 1: PA led patient discharge app for Colorectal Surgery
For the colorectal surgery patients, we have developed a mobile app as a discharge monitoring tool, to support postoperative patients after they’ve been discharged from the hospital.
There’s compelling evidence that postoperative patients are unsure of discharge instructions as they transition from hospital to home. Patients have a lot of questions and uncertainties about what is normal vs. abnormal course of recovery at home. In particular, colorectal surgery patients are very anxious about their complex care needs at home, namely incision, drain and stoma care.
Saira & Alifiya presenting at the PA Poster Presentation on the mobile app. Photo by Anne Dang.
Hence, we’ve developed a discharge mobile app, a monitoring system that essentially checks in virtually with patients once they are home. Inside this free app, we’ve developed a survey, called the “daily health check”, based on a validated score, quality of recovery-15 (QOR-15). In patient-friendly language, the survey asks some of the similar questions we would ask to inpatients. Questions that include: How’s your pain on a scale of 1-10? Do you have nausea? Are you able to eat? Do you have any issues around your incisions? Any problems with the drain or Stoma?” and so on. It is a pretty comprehensive questionnaire. The app also features the ability to take a picture of a concerned wound or stoma.
Patients fill out the survey every day that they’re home for the first fourteen days. If everything is okay, then the patients get a satisfactory progress report at the completion of the survey with some helpful tips and education material. However, if patients’ responses raised red flag symptoms (such as fever, wound complication, ostomy issues, intestinal blockage), then the patients are queued to expect a “call back” from the PA or instructed to go to the ER for severe problems.
On an encrypted provider web dashboard, I look at the patients’ answers to the surveys. For all the “call back” statuses, I follow up with patients with a phone call within one business day, resulting in counselling over the phone or arranging for an urgent clinic appointment. In doing so, patients can bypass the emergency department, where they’d have to wait several hours perhaps to be seen for a relatively minor issue.
For this project, we completed a pilot study which showed that patients loved being able to connect with the a member of the surgical team who knows their medical and surgical course quite well and can provide useful follow up.
Saira with her award winning poster presentation at CAPA conference 2017 for the PA Integrated Monitoring System using a Mobile App to Support Patients at Home after Colorectal Surgery. Photo by Anne Dang.
Right now, we are completing a randomized control trial, which we’re very excited about! We’re almost close to the end and anticipate promising results, namely improving patient outcomes and reduced bounce back to the ER and hospital readmissions.
Research Project 2: Jackson Pratt drain device for Breast Surgery patients
This is a very exciting project for our Breast Surgery patients.
A Jackson-Pratt Drainage System Image from: MSKCC.org
A little bit of background: most of our breast surgery patients, especially those that undergo mastectomies and/or axillary node dissections have a Jackson Pratt (JP) drain placed under the incision. The purpose of the drain is essentially to evacuate fluid that builds up under the incision as part of healing so to prevent any seromas or hematomas that may lead to wound complications.
It’s our clinical impression that a lot of post-operative breast surgery patients return to ER or FD for JP malfunction (i.e. blocked drainage tube, increased incisional pain, swelling and/or erythema, discharge around the drain tube or the incision). These unexpected symptoms cause considerable amount of anxiety in patients and they seek medical attention to be reassessed. Occasionally, increased seroma and hematomas lead to wound breakdown, requiring a prolonged wound closure by secondary intention.
In an attempt to improve patient outcomes for aforementioned drain related problems, we are introducing a JP drain evacuation device. It is essentially a small plastic device that anchors onto the drain tubing at the insertion point and by sliding the device down the tubing, it strips the drain clean of any debris or clot. By introducing this JP-clearing device for post-op use, we hope to evacuate any seromas or hematomas from building up under the breast incision. As a result, we hope to prevent wound-related complications, improve patient outcomes, quality of care and decrease wound related unscheduled visits to the ER or the family physician.
This intervention has shown to work in other settings. So far it’s too early to say what we’ve accomplished. However, with randomization, where some patients receive the JP-clearing device and others do not, we are hoping to have compelling results in the end.
What do you enjoy about research?
Challenging: I enjoy research because it’s challenging and exciting at the same time. Thinking outside the box, problem solving around an idea that I am particularly excited about and then designing and executing the project, is stimulating for me
Benefits patients: Over time, I’ve built research into my PA role at Mount Sinai. I enjoy seeing that patients benefit from the ideas I’ve brought to the table and the processes and clinical frameworks that have improved as a result of my research work.
Fulfilling: My work is often appreciated by both patients and staff for the positive contribution to quality of care, so that’s very gratifying. Also, being able to share the knowledge and research work with my peers at the annual CAPA conferences is very fulfilling. For the last several years, our group at MSH has been recognized for the research work that we’ve done, winning 1st place prize for original research in poster presentations, which is very encouraging.
Saira with her PA colleague Alifiya after receiving their 1st place prize for the CAPA/CPAEA PA Poster Session. Photo by Anne Dang.
What are the benefits of conducting research as a PA?
There are many benefits for conducting research.
Professional leaders: I believe research is the platform whereby leaders in medicine communicate their ideas, inventions, evidence-based guidelines, supporting or disapproving certain ideas etc. So, if PAs conduct and publish their research work, they become leaders in medicine sharing their expertise and highlighting the value they add to the healthcare system.
Challenges status-quo: Another benefit, especially of health promotion research projects, is that it challenges the status quo. Humans, being creatures of habit by nature combined with bureaucracy of often large healthcare organization, it can make difficult to advocate for improving existing patient care. However, as health care advocates, I think PAs can play a vital role in illustrating the need for health promotion as a result of their research work.
Also, in the grand scheme of things the PA profession is fairly new. The more research PAs conduct and publish, the more value we are able to show, advocating for our profession. So, when our PA representatives go to negotiation meetings with those in charge about regulation and accreditation of our profession, it would help tremendously to show the value that PAs have added in many different settings in the Canadian healthcare system.
If more and more PAs publish their research work demonstrating value as a PA in a particular setting,– it speaks volumes to what we’re able to do, collectively, as health care professionals.
What are you changing in your practice as a result of the research you’ve done?
Some of the research projects that I’ve completed, have actually modified the delivery of patient care on our surgical floors. I’ll discuss one example in particular.
Standardized home care pathways- We know there’s strong evidence that unclear communication regarding discharge planning makes it difficult for patients to transition from hospital to home, compromising patient safety.
We noticed that our postoperative breast surgery patients often required home care referrals for routine interventions such as drain and incision care. Since these referrals were completed online by residents rotating frequently, the parameters of care written in the referrals varied. As a result, following problems were identified:
- Referrals often lacked necessary information compromising patient care at home
- Incomplete referrals required a resident to amend referral, delaying patient discharge
- Residents found it very time consuming to type out referrals for routine interventions daily
To address these issues, I created a CCAC template with parameters of care for routine intervention (i.e. JP drain care) that was comprehensive, with all the necessary detail. This template was approved by the staff surgeons, nurses and home care coordinator. Upon approval, the templates were made available on the TCLHIN home care referral portal. With just one click, the template and the entire care pathway would be auto-populated to the referral.
Since the implementation of this tool, there has been drastic reduction in the number of queries regarding referral completion. This also improved the process of discharging patients as the referrals no longer delayed discharges. The residents also benefited tremendously from having pre-approved templates as they could complete referrals in seconds with all the necessary details.
Most importantly, patient care was improved since there was no miscommunication about the care they should receive at home.
That’s just one example of what I was able to do successfully and how it’s actually implemented in my day to day practice.
How do you balance your work and research with clinical responsibilities?
So that’s very challenging. It goes without saying that I am wearing many hats throughout the day. The residents see me as a vital member of the surgical team. Appreciating my clinical role, they are not necessarily aware of my non-clinical duties such as academic and research. So it’s very difficult to balance my duties and find time for my research work.
I’m fortunate to be working with a group of physicians that support my research work and are able to advocate for me to say “Saira needs a few hours set aside where she’s going to catch up some of her projects” and that’s my protected time.
What challenges did you encounter in the beginning of starting research?
I don’t come from a research background. At the very beginning I was very uncertain and fearful because I felt I had no sense of direction – I didn’t know where to begin. I did volunteer for small research projects when I was doing my undergraduate degree, but in PA school, it was such a condensed medical curriculum that I couldn’t free up enough time to delve into research at that point.
That uncertainty was challenging to overcome. I’m fortunate to be working with a group that has very strong research leaders and they’ve supported my ideas, providing constructive feedback and mentoring me along the way.
I encountered early on that we had a research group that consisted of research coordinators and statisticians within the hospital that could help. I can see that could be challenging for beginners to research if they do not have access to these resources. Other challenges can be really getting buy in for your project and finding collaborators. Sometimes finance is an issue, and grants can be difficult to get. However Mount Sinai has a great research group, and we were able to push for ideas and get funding.
Saira presenting at CAPA in Victoria, BC, Poster Presentation