The End

The research is over! This week marked the final presentations for AP Research students and the end of our research projects. After delivering two practice presentations last week under 10 minutes in length (the range we were aiming for was 15-20 minutes), I added another 10 slides to my powerpoint and managed to bring my final presentation up to over 16 minutes. After a morning spent frantically searching for my suit and getting in a few last minute practices, I was relieved to see that I would be giving my presentation in front of only three teachers, two of whom I knew very well.

My presentation went fairly well, and aside from stumbling on my words a few times (say “PCA pump prescription protocol for physicians prescribing pumps to patients” five times fast) and glancing at the clock on the wall every minute or two I think I did as well as I could have. I was well prepared for my oral defense and knew all of my sources by heart, from the information in each source and how it was used to the credibility of each source’s author.

My study’s conclusion, that physicians are not currently doing a sufficient job screening out patients who could suffer ill effects from PCA pump usage, revealed the need for some sort of solution, such as a prescription protocol that physicians could use to properly screen out at-risk patients (my initial planned solution just based on the literature). Asking physicians about the feasibility of such a protocol in a healthcare environment quickly caused me to ditch this solution, as 75% of my respondents believed such a protocol would be an “undue burden” on their work. Thankfully, the short answer questions of my survey allowed me to find an alternative solution to PCA pump prescription errors, increased physician education.

After looking further into the solution proposed by my survey respondents, I found that this solution has failed in the past. After already losing my initial solution (a prescription protocol) due to its lack of feasibility, I was determined to find an aspect of increased physician education that could serve as a viable solution. I found that in the early 2000’s, when healthcare organizations first attempted to lower PCA mortality rates with increased education, they took a very passive approach to this education, creating booklets and videos that physicians could choose to seek out if they desired more information about prescribing PCA pumps. Since this attempt at education didn’t work, and many of my survey respondents still continue to call for increased education today, I believe a more active approach to physician education could find more success. This approach, which could consist of mandatory training for PCA pump prescribers and opioid medication providers in general, will hopefully aid physicians in identifying patients who should not be given PCA pumps.

A solution to this problem could save millions of dollars per year for taxpayers, hospitals, and patients and hopefully work to lower the high mortality rate of PCA pump errors, which currently rides at over four times that of any other medication related error.

Thank you for reading my blog posts and following my research!

WORD COUNT: 533

Practice Presentation Reflection

This last week I gave my first practice presentation, which was recorded and sent back to me for analysis. With one more chance to practice this Saturday (before the final presentation next week), I spent most of my time working this week to fix up my presentation. While I had few problems regarding my presentation skills, I had much more to add in terms of my presentation’s content, specifically in my methodology/discussion and use of visual aids.

Unfortunately, I have a tendency to talk very quickly during presentations (likely due to nerves). During my recorded practice presentation, I managed to turn the presentation that took my 16-18 minutes normally into a 9 minute presentation. While this puts my far short of the 15-20 minute time frame, it also means I have a lot of room left to incorporate more material into my slides. Besides this speed reading, the only other problem with my presentation skills was my tendency to look at the slides regularly, which messes up the flow of the presentation and makes it seem as if I don’t know the material I am presenting by heart.

Those who viewed my practice presentation found it to be a little boring, as I had many long slides inundated with text all throughout my powerpoint. After my first practice, I cut down a majority of my long slides, either by removing text and adding it to my script or by splitting slides with more than 4 points into multiple slides with less text. With all of these additions being made to my script, I also went through the script from the beginning and simplified it, ensuring that any complicated language was put as simply as possible (this both makes it easier to memorize and easier for the audience to understand). With regards to visual aids, I found that the one picture (of a PCA pump) and two tables (my results) were not enough to sufficiently keep the audience's attention through a 22 slide presentation. I added 3 pictures and a graph to my updated slideshow (28 slides in total), which should be more than enough to both help get my points across to the audience and keep them engaged with my presentation.

With regards to my methodology and discussion sections, I added a few slides to both explain how I formulated my survey questions and create a direct link between my results and my conclusion. I had an especially hard time creating a discussion section, as everything I would say in my discussion was more concisely stated in my conclusion just a slide later. I ended up merely using the discussion section to tell the audience about some interesting things shown by my data that I did not explicitly mention before (and that didn’t directly relate to the conclusion).

Saturday will be the next practice presentation opportunity for me, while the final presentation will also take place towards the end of next week. My last blog post for this project will be a reflection on my final presentation.

Almost done!

WORD COUNT: 515

Presentation Preparation

Hello!

Last week I finally finished my research paper in its entirety, and submitted it for consideration by the College Board. After frantically spending the few nights before my submission reading over my paper and removing any identifying characteristics (my name, school, contact information), I sent my paper to a few friends and family members who had no prior knowledge of my research project to ensure that my literature review properly explained the background of my topic and conclusion followed logically from the introduction and results. After a few edits to the formatting and in-text citations, I felt comfortable submitting it as my final paper and using it to begin writing my presentation.

Looking at the rubric of the College Board presentation, I have found it to include several specific requirements that one would not normally think to include in a presentation, mainly in terms of the “reflection” section of the rubric. This section requires me to explicitly include in my presentation the process by which I thought through my research methods, results, and then conclusion, similar to how I have shown my research development through blog posts.

With regards to my actual powerpoint slides, I have been focused on limiting each of my slides to only a few bullet points, and writing out a detailed script to fill in the missing parts. Last year we were taught to limit the information in our powerpoint slides to ensure that we were essential as speakers (if everything you say is in the slides then there is no point in you presenting). Using short bullet points both keeps the audience engaged and gives me a small indication of what I am going to say next. An interesting template is also instrumental in keeping the audience’s attention, and I decided to import one into Google Slides that fit my topic, eventually deciding on a medicine-themed template.

The rubric indicates that a strong presentation should make use of visual aids. The best place to include this would be when showing the data obtained in the study as a graph. Unfortunately, my data is not well suited to a graph, and I am currently considering using a chart instead (this is what I used in my research paper, see below).

Results

Table 1: Criteria Evaluation levels

Criteria being considered	Places with protocol	Places without a protocol
Obesity	None	25%
Substance abuse	None	0%
Sleep apnea	None	0%
Cognitive Impairment	None	63%
Asthma	None	13%
Conflicting medications	None	50%
Other common criteria (reported from short answer questions)	None	Pre-hospital pain level (13%), Complexity of the surgery (13%) Urgency of the pain and how rapidly the medication need to take effect (50%) Patient’s physical ability to control the PCA pump (50%)

Table 2: Burden on and value to the Healthcare system

Question	Places with protocol	Places without a protocol
Does your hospital have a PCA pump prescription protocol	None (0%)	None (0%)
Do you feel that a procedure/protocol that all staff must go through prior to prescribing a PCA pump would be beneficial for patients?	None	100%
Would the protocol be a burden?	None	75%

Since this is the week of practice presentations, I will use the feedback I get from my practice run to modify my slides/visual aids for the final presentation (next week!). Hopefully this final step in my research project will be a success, and in my next blog post, I will discuss the completion of my presentation slides, my feelings about my practice presentation, and my preparation for my final presentation.
WORD COUNT: 592

Presentation Skills and Content

I have spent this past week writing my powerpoint presentation and script, and generally planning out how the presentation will go. As my AP Seminar class last year consisted of many recorded presentations, I decided to look back over the recordings and identify things to improve on. The main problems with my presentations in the past have been in my body language and tone.

With regards to my body language, I need to be more engaged with my audience. I had a tendency to stand with my hands crossed in front of my body while speaking, a very closed-off stance. A more open stance, perhaps with my hands to the side, would be more appropriate for this research presentation. In addition, adding more movement to my presentation, possibly by switching sides of the room every few slides, could keep my audience interested with my presentation.

In addition to improving my body language, I need to increase my volume a substantial amount and mumble less, as my quiet and strung-together words were lost in my Seminar video recording. Reducing my use of filler words such as “um” and “like” will improve my presentation as well, and writing a detailed script (and practicing it often) should allow me to avoid these meaningless words. Finally, I decided that my voice could use a lot more variation and emphasis, as it can come across as very monotonous when I use the same impassive voice to say everything.

With regards to the actual content of my presentation, the vast majority of my time will be spent on the background behind my research and explaining my question in detail. As PCA pumps and anesthesiology devices in general are not common knowledge, establishing a base level of understanding in my audience will be essential in order to get my results across. During my practice presentations, I will be sure to determine whether my explanation can effectively get background information on PCA pumps across to my audience. In addition to this background information, I need to make the impact of my research clear to the audience (both the economic impact and the impact on patient health).

For my methodology, results, and conclusion, I will use graphs and charts (both of which I relied heavily upon in my AP seminar presentation) to make my findings perfectly clear to my viewers. In addition, direct quotes from some of my survey respondents will allow me to show both the impact of my research and the proposed solution: increased physician education.

Over the next week, I will continue to write my script and work on my powerpoint presentation, as well as revise my paper for the last time, mostly to finish compiling my sources into one concise works cited page.

WORD COUNT: 465

Finishing up my paper

Hello again!

As this research project is coming to a close, I have spent the past week combining all the different pieces of my research paper: the abstract, literature review, methodology, results, and discussion. The most challenging parts of this were balancing the tone of the paper as a whole, verifying all of my sources, and writing the abstract.

As the different parts of this paper were written over a few months, the tone of each section was slightly different, likely influenced by my plans for how the research would end at the time and what results I was expecting (this changed as I met consultants and started receiving results). I went through the entire paper after writing my discussion and looked at it again with the knowledge that anesthesiologists didn’t want the institution of a PCA pump prescription protocol but rather increased education on opioid medications and PCA instruments. I rewrote several sections to improve the flow of the entire piece, but was sure to also not allow my final results to color my initial hypothesis and background.

Verifying my sources was incredibly challenging (and is still an ongoing process). As the sources were compiled over several months, some of them have been put into a bibliography while others were stored on many different documents in different formats. In addition to putting all of my sources into my final paper in a works cited page, I have been going through each source and ensuring it accomplishes what I intended. This entails searching for each source online, identifying what the claims the source was supporting up in the paper, and determine whether or not the source is actually able to back up my paper’s claims. This was challenging, as the sources I had that didn’t have direct links were usually hidden in large medical databases. In addition, it seems that my access to MedScape, a website from which I had found a large number of my sources, took a large number of their anesthesiology papers off the free section of their website. Rather than pay to gain access to these papers, I have had to look for alternative sources to support the same points in my paper, a task that has taken multiple days so far.

Writing the abstract for this paper was probably the easiest task I have had to achieve this week. Once the results and discussion were completed, writing the abstract was simply summarizing each section I had already finished. The most challenging part of this was managing to get the material from a 4000 word paper into my 250 word abstract without losing any meaning. After writing a couple of drafts that I was unable to cut below 500 words, I decided to cut out a majority of the background information from my abstract and instead focused on the results and solution I found: that doctors were failing to properly screen out patients from PCA pump complications and needed more education on opioid medications and delivery systems.

Over the next week, I will finish my work verifying my sources and begin work on my presentation, which I will practice and complete in the upcoming weeks.

Initial Results

Hello all!

I have finally received data from anesthesiologists at every institution I have contacted, and was pleased to find that the physicians completing my surveys took the time to write detailed responses to my short answer questions, explaining their views on why PCA pump prescription protocols would help patients but are also detrimental to their work. Every single response I have received thus far has indicated that instituting a protocol every physician has to go through before prescribing a PCA pump would serve to benefit patients. However, 75% of my respondents also indicated that this protocol would be a detriment to their work (when taking into account the time it would take to go through every test on the protocol).

Many of the anesthesiologists who took my survey suggested ways to remedy this discrepancy, with most suggesting that increased education of physicians on the possible complications that could arise from PCA pumps could reduce the need for a prescription protocol. Respondents to the survey expressed that a physician should be incredibly familiar with the details of the patient’s medical history (reducing the need for a PCA pump prescription protocol) and that anybody with the power to prescribe opioids (not even just in PCA pumps) should undergo mandatory additional training.

In hospitals without a current PCA pump prescription protocol, about half of the physicians surveyed took into account a patient’s cognitive ability and physical ability to handle a PCA pump before prescribing one. One respondent mentioned that if a patient seemed confused about the pump technology and application, the hospital would have a nurse educate said patient and family members on rules of PCA pumps and important complications that could arise.

I made sure to attach a contact form to both the beginning and end of my survey, in case any of the survey takers had any questions/comments, and was pleased to hear back from a few physicians requesting additional information on a few of my questions. The comments I received revealed that I may have failed at some times to make a very important distinction: while a history of substance abuse is definitely a factor that affects how exactly a PCA pump should be programmed or whether it is the ideal pain management solution for a patient, it is not a pre-existing condition that would make a PCA pump immediately apparent as an ineffective management tool. When programmed to account for a history of or ongoing substance abuse, studies have found PCA pumps to be incredibly effective in treating the post-surgical pain of drug users (or past abusers).

I hope to finish up the rest of my research in the next week, and am still taking in survey responses from one of the larger hospitals in the Scottsdale area. While I have received at least one response from every major hospital in the city, my overall number of responses is still very limited and should grow in the coming week. Next week I will provide an updated view of my results and analyze any large changes in my data.

WORD COUNT: 512

Research Update and Survey Questions

Over the last few weeks, I have sent out my survey to physicians and anesthesiologists at the numerous large hospitals in the Scottsdale area and have begun to categorize and analyze my responses. Just to make my process as transparent as possible, I have included all the questions I asked in my survey below this short post.

I set up my survey through Google Forms to then send all of my data into a spreadsheet, and I am currently in the process of picking out common responses and themes (from the short answer questions of my survey) in order to make broader conclusions. This is a data analysis method identified by award-winning researcher John Creswell as one of the most effective ways to analyze a qualitative survey, and has so far allowed me to discover that physicians tend to look at the most obvious pre-existing conditions that can interfere with PCA pumps (such as obesity, which is often readily apparent) when they don't have a PCA pump prescription protocol in place. This was exactly as I expected (and what seems most logical), and I hope to find out more about whether or not physicians are looking at the other pre-existing conditions (that may not be as readily apparent) that can cause death or injury when mixed with PCA pumps.

1. Which Hospital or Healthcare institution do you work for?
2. How often do you prescribe PCA pumps as a part of your job at your hospital (daily, weekly, monthly, etc.)?
3. Does your hospital have a certain protocol/procedure you must go through before prescribing a PCA pump in order to ensure the patient can medically or mentally handle the pump?
1. If so:
1. What are the main features of this protocol?
2. Does your protocol include asking/testing patients for any of the following? (check all that apply)
1. Sleep apnea
2. Cognitive Impairment (either the Mini-Mental Status Exam or another test to determine if the patient is suffering from any level of cognitive impairment)
3. Asthma
4. Mental Illness (either using the Mental Status Exam or another test to detect the presence of mental illness in a patient)
5. Obesity
6. Substance Abuse
3. Of all the times when you prescribe a PCA pump, how often do you actually follow this protocol completely?
4. Are there any additional tests you run or conditions you consider before prescribing a PCA pump to a patient? (These would be in addition to the 6 conditions listed in the second question above)
5. Do you feel that the current protocol procedure you have is a detriment to your work? (Please take into account factors such as time, stress, and strain on hospital resources that this protocol may incur)
2. If not:
1. What specific criteria do you consider before prescribing a PCA pump to a patient?
2. Do you feel that a procedure/protocol that all staff must go through prior to prescribing a PCA pump would be beneficial for patients?
3. Do you feel that having a PCA pump prescription protocol that you would have to complete before every time you prescribe a PCA pump would be a detriment to your work? (Such a protocol would likely require looking through the medical history of the patient and testing for conditions such as sleep apnea or some level of cognitive impairment. Please take into account factors such as time, stress, and strain on hospital resources that this protocol could lead to.)
4. How long does it typically take you to prescribe a PCA pump?

Methodology

My research on this topic will be primarily conducted through a survey of practicing anesthesiologists. In order to discover whether or not the current practice of physicians using their personal judgement and criteria before prescribing a PCA pump ensures patient safety, I first have to find out what criteria physicians tend to personally consider before every PCA prescription they write. My survey will reveal what criteria physicians consider at hospitals where there is no PCA pump protocol, and what criteria physicians have to look at at hospitals where there is such a protocol in place. Comparing these two will allow me to determine if physicians are personally considering the issues that most commonly lead to PCA pump complications, such as asthma, obesity, conflicting medications, and confusion/delirium.

My survey will split into two large sections, with a group of questions for hospitals without PCA pump protocols and a group for hospitals with protocols. For hospitals with protocols, questions will focus on what exactly the protocol requires physicians to check out, and how much of a detriment following the protocol places on the doctor’s work (such as wasting large amounts of time running non-essential tests). For hospitals without a protocol, the questioning will be far more intensive, as I will attempt to find out what the physicians personally consider prior to prescribing a pump with both yes/no questions and short answer questions. I will read over the results to the short-answer questions to identify common themes (for example, that most physicians tend to ask patients if they have sleep apnea or take any prescription medications). This will allow me to eventually make conclusions regarding the tests most doctors run before prescribing PCA pumps. This survey design gives this research both a quantitative and qualitative aspect, eliminating many of the restrictions to purely qualitative or purely quantitative studies (Creswell).

For my sample, I am looking for anesthesiologists at hospitals. This survey was sent in an email to the head of anesthesiology at every major hospital in the Scottsdale area and requested that they give it to all anesthesiologists in their department, ensuring a large amount of data from each healthcare facility. Major hospitals have just been defined as those that have a department of anesthesiology, as smaller hospitals don’t have this distinct department and it would be impossible to efficiently determine who to contact for questions regarding anesthesiology at such hospitals.

In conjunction with this survey, I will be using public health data to look at the amount of time it takes to run tests for several of the pre-existing conditions that complicate PCA pumps, such as sleep apnea and confusion/delirium. This will allow me to determine whether or not running  these tests places an undue strain on the health care system, a strain that could also cause negative patient outcomes.

In my next blog post, I will look at more of the data analysis techniques I am using on my survey results and tie them in with the data I have found on public health databases for running patient tests.

WORD COUNT: 511

Groups that are ill-suited for PCA pumps

Hello again! In my first blog post, I identified several groups of individuals that were ill-suited mentally or medically for PCA pumps. Studies by the Institute for Safe Medical Practices have revealed that harmful errors were more likely to impact patients in these specific groups (Vicente, Kada-Bekhaled, Hillel, et al.). The patients who frequently cannot handle the responsibility of PCA pumps include infants, confused/obstinate patients, and substance abusers (D’Arcy). Patients who cannot medically handle the PCA pumps include asthmatic patients, obese patients, patients on other specific medications, and patients with sleep apnea. In this post, I am going to explain why each of these patient groups should not be prescribed PCA pumps and identify the risks that could face them if they were improperly prescribed one.

Using a PCA pump requires a patient to be capable of following directions, mentally aware, and responsible. For this reason, children under the age of seven and patients who suffer from confusion or disorientation should not be given PCA pumps. Some physicians may even choose to avoid prescribing these pumps for overly obstinate patients who have a poor ability to follow directions (Moe and Maloney). Substance abusers and addicts, other groups of patients that typically suffer from irresponsibility, can have many adverse reactions to the opioids in PCA pumps if their condition is not known to their healthcare provider. Even though these patients are typically assumed to be incapable of safely "self-medicating," clinical trials have found PCA pumps to be “useful for pain relief in this population” if the pump is programmed to allow for modified dosages (usually higher to account for patients developing a tolerance for opioids) and if nurses are alerted to watch over these patients closely (Prince). Substance abusers and other mentally impaired patients can all benefit from the technology of PCA pumps, as long as their healthcare provider correctly modifies the pump's programming to account for the patient's condition. For this reason, it is essential that physicians use established and common psychiatric examinations such as the Mental Status Exam (MSE) to determine the mental awareness and capabilities of all patients prior to PCA pump prescription (Goldberg).

Beyond being mentally incapable of handling a PCA pump, many patients have pre-existing conditions or conflicting drug prescriptions that could make a PCA pump dangerous. The Center for Medicare and Medicaid, a large government medical database and research facility, has found several case studies of chronic sleep apnea causing respiratory depression (essentially a deep sleep that leads into death) in patients treated with PCA pump opioids. Patients who take other drugs (either legal or illegal) can be exposed to dangerous effects if the medication they take reacts with PCA opioids. A detailed medical history can allow the physician to screen out and plan alternate pain management strategies for patients who take these conflicting drugs (Prince).

Most of the groups that commonly suffer complications from PCA pumps can be easily screened out. This can give physicians time to either modify the pump’s programming or design an alternative pain management strategy to protect the patient. With these modifications, PCA pumps are still the most effective and safe method for postoperative pain management.

WORD COUNT: 527

Hello all! My name is Arjun Gupta, and I am a senior at BASIS Scottsdale conducting research as a part of the AP Research Capstone course. Over the next few months, I will implement a research plan and analyze my results, finishing my senior year off with a complete research paper, presentation on my findings, and oral defense. My research focuses on selection protocols for PCA pumps, medical devices commonly used for post-surgical pain management in healthcare institutions all around the world. While there is an abundance of research available on the pumps themselves, there is not nearly enough on the patients being given these pumps, a surprising deficiency that I hope to address with this study.

PCA pumps work by delivering a preset dose of opiates directly into the bloodstream when the patient presses a button (called a “dosing button”). The idea behind these pumps is that patients can receive medication whenever they feel pain (up to a certain preset amount) and won’t be able to over-sedate themselves, as they will not be physically capable of pressing the dosing button when they are close to becoming over-sedated (Physician-Patient Alliance for Health Safety). PCA pumps are now the most common method of postoperative pain management, as several NIH-funded clinical trials have shown they drastically reduce the risk of over-sedation while also providing the highest level of patient comfort (Fitzgibbon, Ready, and Ching).

While PCA pumps are very common in post-operative care today, they are not the ideal pain management devices for everybody. Patients who cannot handle the responsibility of the PCA pump include infants, confused/obstinate patients, and substance abusers (D’Arcy). Patients who cannot medically handle the PCA pumps include asthmatic patients, obese patients, patients on other specific medications, and patients with sleep apnea. Studies by the Institute for Safe Medical Practices have shown that harmful errors are more likely to impact patients in these specific groups (Vicente, Kada-Bekhaled, Hillel, et al.).

With all the patient groups ill-suited for PCA pumps, errors with this form of opioid administration have a big impact on our healthcare institutions. While PCA pumps are still the most effective form of postoperative pain management for most patients (Fitzgibbon, Ready, and Ching), complications from these pumps can lead to negative economic consequences and loss of life.

Most of the risk factors for PCA pumps and complications associated with the medications can all be minimized through aggressive patient selection. Taking a detailed medical history from patients and creating a list of factors to examine before prescribing a PCA pump can easily prevent complications regarding sleep apnea, conflicting medications, and confusion/delirium. While bypassing these precautions may allow healthcare facilities to save resources and may also reduce the amount of time a patient suffers in pain, there has been limited research on how much exactly it saves. This research study will determine whether or not the current practice of doctors using personal judgement to determine whether or not a patient can handle a PCA pump is enough to ensure patient safety or if the development and implementation of an official protocol would be safer, taking into account the heightened burden that such a protocol might have on a hospital's time and resources.