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.

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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.

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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.